Building links between town and gown: an innovative organisation in south-eastern Melbourne.

Primary care is the foundation of a nation's health care system. Real world research is a requirement of a health system built to deliver the benefits of a strong primary care community. In the last decade, new approaches to optimising the impact of research on practice and policy have been formulated across disciplines. However, in Australia, the primary care research community remains small and primary care researchers are not well represented in either receiving support for or governing research. While practice-based research networks (PBRNs) have brought GPs and, sometimes, other clinicians together with academics, few have managed to bring local decision makers and other primary health care stakeholders into partnerships where they can work together on common problems. This paper outlines a novel three-way partnership between a health authority, a primary care organisation and a university in the south-eastern suburbs of Melbourne. A case study was undertaken based on author experience of the Southern Academic Primary Care Research Unit (SAPCRU) and semi-structured interviews with representatives from partner organisations. Interviews elicited perceived barriers and facilitators, including complex financial, human resources and governance challenges, associated with bridging the gap between research and practice. It was found that SAPCRU has been successful in engaging with research partners and has begun to develop links with policy makers and orient research themes to the needs of its varied communities. Especially with the introduction of Primary Health Networks (PHNs), the model has the potential to translate to different settings but barriers should be noted.

Rhino-orbital-cerebral infection by Syncephalastrum racemosusm.

Invasive rhino-sinusitis infection has been known to be caused by zygomycetes commonly belonging to the genera Rhizopus, Mucor and Rhizomucor. We report a middle aged diabetic gentleman who had invasive rhino-orbital-cerebral infection with Syncephalastrum racemosum. This genera belonging to zygomycetes group of fungi which usually causes skin and soft tissue infection but invasive infection with this fungus is rarely known.

A prospective, randomised, placebo-controlled trial of postoperative oral steroid in allergic fungal sinusitis.

The aim of this study is to determine the effectiveness of postoperative oral steroid in controlling disease in patients with allergic fungal sinusitis (AFS). The study design includes prospective, randomised, double blind,placebo-controlled trial using oral prednisolone.Twenty-four patients diagnosed with AFS underwent sinus surgery (endoscopic sinus surgery with or without open surgery) to completely excise disease. Patients were randomised to receive either oral steroid (n = 12) or placebo(n = 12) soon after surgery. All patients were also administered itraconazole and steroid nasal spray in the postoperative period. Subjective evaluation of symptom relief and objective evaluation by rigid nasal endoscopy at 6 and 12 weeks following surgery was performed. After12 weeks, the code was broken and the two groups of patients were identified to note their response to treatment.At 6 weeks, complete relief of preoperative symptoms was obtained in eight patients who had received oral steroid and none who had received placebo (p = 0.001). Partial relief of preoperative symptoms was obtained in four who had received oral steroid and eight who had received placebo.Nasal endoscopy revealed that 8 of 12 patients who had received oral steroid and 1 patient who had received placebo were disease free (p = 0.009). At 12 weeks, complete symptom relief was obtained by all patients who received oral steroid but only one who received placebo(p = 0.0001). Nasal endoscopy at 12 weeks revealed that all 12 patients who had received oral steroid and only 1 patient (the same patient) who had received placebo were disease free (p = 0.0001). In conclusion, postoperative oral steroid in a tapering dose produces significant subjective and objective improvement of patients with AFS. It is also effective in preventing early recurrence. Inclusion of post operative oral steroid therapy for at least 12 weeks is recommended in all patients who undergo excisive surgery for AFS.

Fatal cerebral abscess caused by Cladophialophora bantiana.

Primary cerebral phaeohyphomycosis is caused by pigmented fungi that exhibit distinct neurotropism often in immunocompetent individuals. A 20-yr-old male presented with multiple brain abscess which was subsequently proven microbiologically to be due to Cladophialophora Bantiana. In spite of near total excision and appropriate antifungal agents succumbed to his illness. We report this case to highlight its rarity and high mortality in an immunocompetent host. There is no initial clinical or laboratory feature that makes a preoperative diagnosis possible and relies on microbiological confirmation.

Promoting e-communication-lessons from a feasibility study.

There has been a rapid uptake in the use of computers in general practice during the past decade. General practitioners initially used computers primarily to generate prescriptions, but have increasingly adopted computers for health record keeping. While most practices are now receiving pathology and radiology results via the internet, electronic communication (e-communication) between GPs and other health care providers remains limited. Making referrals, communicating to and from medical specialists and allied health practitioners, and obtaining important health information from hospitals and other health care organisations have all proven difficult to implement in electronic form.

Diabetes 'cycles of care' in general practice - do government incentives help?

BACKGROUND: In 2001 the Australian government introduced financial incentives to encourage general practitioners to improve their care of people with diabetes. This article examines the extent to which GPs are implementing the diabetes 'cycle of care' for patients, and the barriers and enablers to its uptake. METHODS: Semistructured interviews with key informants within purposefully selected general practices in one division of general practice in southeast Melbourne, Victoria. RESULTS: General practitioners and practices provide 'cycles of care' for their diabetic patients in a range of ways. A systematic approach to diabetes appears more important than government incentives. DISCUSSION: There are numerous barriers to the uptake of government incentives for improved diabetes management, most of which relate to difficulties in making changes to current practice and adopting a systematic approach to the implementation of new initiatives. General practitioners and general practices need a broader support strategy than just government financial incentives if systematic chronic disease management is to be more widely adopted.

Mycological profile of fungal sinusitis: An audit of specimens over a 7-year period in a tertiary care hospital in Tamil Nadu.

BACKGROUND: Fungi are being increasingly implicated in the etiopathology of rhinosinusitis. Fungal sinusitis is frequently seen in diabetic or immunocompromised patients, although it has also been reported in immunocompetent individuals. Invasive fungal sinusitis, unless diagnosed early and treated aggressively, has a high mortality rate. AIM: Our aim was to look at the mycological and clinical aspects of fungal sinusitis in a tertiary referral center in Tamil Nadu. DESIGN: This is a retrospective audit conducted on fungal culture positive sinus samples submitted to the Microbiology department from January 2000 to August 2007. Relevant clinical and histopathological details were analysed. RESULTS: A total of 211 culture-positive fungal sinusitis samples were analysed. Of these, 63% had allergic fungal sinusitis and 34% had invasive fungal sinusitis. Aspergillus flavus was the most common causative agent of allergic fungal sinusitis and Rhizopus arrhizus was the most common causative agent of acute invasive sinusitis. A significant proportion of these patients did not have any known predisposing factors. CONCLUSION: In our study, the etiology of fungal sinusitis was different than that of western countries. Allergic fungal sinusitis was the most common type of fungal sinusitis in our community. Aspergillus sp was the most common causative agent in both allergic and chronic invasive forms of the disease.

Paecilomyces pyelonephritis in a patient with urolithiasis.

Fungal organisms are increasingly implicated in nosocomial urinary tract infections. Although Candida, Mucor and Aspergillus are the most commonly identified species, rare fungi are also occasionally observed to infect humans. Misidentification of the organism could result in treatment with an inappropriate antifungal agent, which could result in a florid fungal pyelonephritis. We report the occurrence of fungal pyelonephritis in a patient with stone disease secondary to Paecilomyces variotii. This case report emphasizes the need for an accurate identification of the organism and early and appropriate treatment.

Health professions' education and practice: A commentary on transformation through the internet.

The Internet, in all of its forms and functions, is well on the way to becoming the most ubiquitous technology of the 21st century. It is changing the way the world does business, the way formal education is conducted, and the way humans interact with each other. The Internet already has become an invaluable tool for formal health education and for the delivery by health professionals of information, training, and education to their employees and patients. With new paradigms for health on the horizon, modem Internet technologies will transform health care practice and systems delivery. In this report, the authors focus attention on the use of distance learning/distance education technologies and their relationship to, and use in, the health professions.

Disseminated histoplasmosis.

OBJECTIVE: To study the clinical features and natural history of disseminated histoplasmosis(DH) in India. METHODS: We retrospectively analyzed the data obtained from the in-patient medical records of adults (age > 13 years) diagnosed to have DH during the period from January 1989 to December 1999. DH was diagnosed when histologically compatible intracellular organisms were present or Histoplasma capsulatum was obtained in culture from the extrapulmonary sites. RESULTS: Nineteen patients (18 male and 1 female) were diagnosed to have DH. Diabetes mellitus and HIV infection were the most common co-morbid conditions. Weight loss, fever and oropharyngeal ulcers were the commonest symptoms. Physical signs included hepatosplenomegaly, oropharyngeal ulcers and lymphadenopathy. The diagnosis was confirmed by histopathology and/or culture from the following sites: bone marrow, adrenal gland, lymph node, oropharyngeal ulcers, rectal mucosa and skin. Two patients were treated with Amphotericin B, 6 with various azoles and 3 had Amphotericin B followed by various azoles. Among the eleven treated, 7 were cured, 2 improved, 1 had a relapse and 1 patient died. CONCLUSION: DH is not uncommon in India and should be considered in the diagnosis of patients with prolonged fever, weight loss, oropharyngeal ulcers, hepatosplenomegaly, lymphadenopathy and adrenal enlargement. Correct diagnosis and treatment leads to a favourable outcome.

Recurrent Hepatocellular Carcinoma in Patient with Crohn's Disease: Incidental or Expected Outcome of Azathioprine?

Hepatocellular carcinoma (HCC) usually occurs in patients with underlying risk factors such as liver cirrhosis and chronic hepatitis B. Although patients with Crohn's disease (CD) are at an increased risk to develop malignancies such as colon cancer, the incidence of HCC in this population is extremely rare. We report a case of 62-year-old male with long history of CD treated with azathioprine (AZA) and aminosalicylic acid (ASA) who was incidentally diagnosed with HCC, for which left hepatectomy was done. Four years later during routine follow-up, patient had another hepatic lesion and underwent resection of the mass. The mechanism of occurrence of HCC in patient with CD is still controversial and may include immune mediated changes and medication related complications. AZA was reported in all case reports of CD that developed HCC. Through this report we hope to explore the complex pathophysiological mechanisms contributing to the development of HCC in the Crohn's disease patient population.

Epidemiology of systemic mycoses among renal-transplant recipients in India.

BACKGROUND: Systemic mycoses have a high impact on tropical renal-transplant recipients. METHODS: Data from 1,476 primary renal-transplant recipients was prospectively recorded from 1986 to 2000 at a single center. Cumulative incidence of systemic mycoses, its time of occurrence, risk factors, outcome, and postmortem findings in 30 patients with systemic mycoses were analyzed. RESULTS: A total of 110 episodes of systemic mycoses occurred in 98 patients. The fungal genera Aspergillus, Cryptococcus, and Candida constituted 61% of pathogens, 45% localizing to the lungs. Cytomegalovirus (CMV) disease caused a 5-fold and chronic liver disease a 2-fold increase in systemic mycoses. Tuberculosis (TB) with or without nocardiosis was a significant coinfection. Cyclosporine (CsA) was associated with nearly a 4-fold risk of systemic mycoses less than 6 months from the time of transplantation as compared with prednisolone+azathioprine (PRED+AZA) therapy. Overall, the probability of survival with systemic mycoses was 73.4%, 60.8%, 39.5%, and 25.6% and was 92.5%, 87.5%, 80.0%, and 75.5% without systemic mycoses at 1, 2, 5, and 10 years, respectively (P<0.0001). An extended Cox model with time-independent and dependent covariates showed greater than 15 times the risk of death among those who develop systemic mycoses. Similarly, Posttransplantation (postTX) TB+/-Nocardiosis, preTX TB, CMV disease, diabetes mellitus, PTDM, chronic liver disease (>40 months), and Pred+AZA immunosuppression (>2 years) had 3.5, 1.5, 2.9, 1.9, 1.4, 1.6, 2.3 times the risk for death, respectively, as compared with those who did not have those risk factors. CONCLUSIONS: There is a recent predominance of Aspergillus among the transplant recipients. The risk factors for systemic mycoses are CMV disease, chronic liver disease, and hyperglycemia, and TB is an important coinfection. Systemic mycoses increased in the early postTX period with CsA. The risk factors for death are systemic mycoses, CMV disease, chronic liver disease (>40 months), diabetes mellitus, and Pred+AZA immunosuppression (>2 years). Overall, the probability of survival with systemic mycoses was poor; however, survival has recently improved.

Endotoxin protection from oxygen toxicity: effect on pulmonary neutrophils and L-selectin.

The mechanisms by which sublethal doses of endotoxin protect against hyperoxic lung injury are not completely understood. We hypothesized that endotoxin treatment would result in a decreased inflammatory response to hyperoxia and that this would be accompanied by activation of neutrophils (as evidenced by loss of L-selectin) in the peripheral circulation. Adult rats were injected with endotoxin 0.5 mg/kg prior to and 24 hr after onset of exposure to > or = 98% O2. After 56 hr of hyperoxia, pulmonary neutrophils were lower in the O2/endotoxin group compared to O2 controls as measured by myeloperoxidase in lung homogenates and neutrophil counts in bronchoalveolar lavage fluid. Circulating neutrophils were also significantly lower in the O2/endotoxin group compared to O2 controls at 56 hr. Expression of the neutrophil adhesion molecule, L-selectin, was lower at 4 and 24 hr in the endotoxin-treated rats compared to O2 controls. There were no differences at 48 hr. Expression of CD18 rose significantly in the O2/endotoxin group after 4 hr, but thereafter did not differ from O2 controls. In summary, endotoxin protection from O2 toxicity was associated with reduced neutrophils in the lung and a loss of L-selectin from peripheral blood neutrophils.

Resourcing nursing education through collaboration.

The nursing shortage is also a nursing faculty shortage. The shortage of nurses can only be managed if the shortage of faculty is addressed. The profession needs creative and rigorous "research and development" strategies to secure sufficient educator resources across practice settings. Recent position statements of the American Association of Colleges of Nursing and the National League for Nursing on nursing education and the preparation of nurse educators recommend specific actions to meet these needs. The author calls for purposeful and creative collaboration between educators in academic and service settings to resource nursing education, now and in our future.

In situ remineralisation of eroded enamel lesions by NaF rinses.

OBJECTIVE: The purpose of this pilot study was to evaluate the remineralisation of eroded enamel by NaF rinses in an intra-oral model. METHODS: Serving as their own control, subjects (N=80) participated in a randomised, four-leg (20 subjects/leg), 28-day, parallel design study. In each leg, each participant wore a customised orthodontic bracket attached to a mandibular molar that contained one tooth block having an initial erosive lesion (0.3% citric acid, pH 3.75, 2 h). Within the 28-day period, participants engaged in twice-daily brushing for 1 min with a fluoride-free dentifrice followed by 1-min rinsing with one of the following aqueous rinses: fluoride-free (0 ppm F), 225 ppm F, 225 ppm F plus functionalised ß-tricalcium phosphate (fTCP), and 450 ppm F. Following intra-oral exposure, appliances were removed and specimens were analysed using surface microhardness (SMH) and transverse microradiography (TMR). RESULTS: Statistically significant (p<0.05) remineralisation, as determined by SMH and TMR, of the eroded enamel relative to baseline occurred for each fluoride system. No significant differences in SMH were observed amongst the fluoride groups (p>0.05), however, 225 ppm plus fTCP produced 27% and 7% SMH indent length reduction relative to 225 ppm F and 450 ppm F, respectively. No significant differences in TMR were observed amongst the fluoride groups (p>0.05), however, 225 ppm F plus fTCP and 450 ppm F produced significant (p<0.05) mineral gains relative to the fluoride-free control, whilst 225 ppm F did not (p>0.05). Relative to the 225 ppm F group, the 450 ppm F and 225 ppm F plus fTCP groups produced 65% and 61% greater mineral change, respectively. CONCLUSIONS: These pilot results demonstrate this model is sensitive to fluoride and that addition of fTCP to an aqueous rinse containing 225 ppm F may provide significant remineralisation benefits. Therefore, the combination of relatively low levels of fluoride and fTCP might be an effective alternative to a high fluoride treatment for anti-erosion benefits.

Disseminated protothecosis.

Here is presented, a rare case of disseminated protothecosis in a 10-year-old boy with combined immunodeficiency, hitherto unreported from India. Even though it is difficult to diagnose clinically, observation of the sporangiospores within the sporangium in culture gives the accurate laboratory identification of Prototheca spp. In this patient, failure to eradicate the infection with amphotericin B and recurrence with olecranon bursitis along with skin lesions and splenomegaly was observed. Disseminated protothecosis in a child with combined immunodeficiency and failure to eradicate the infection with amphotericin B is reported.