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Year of Publication
1.  Medicines shortages—unpicking the evidence from a year in South Africa 
The Australasian Medical Journal  2014;7(5):208-212.
Although medicines shortages are a persistent and challenging problem for all health systems, the reasons for such shortages vary considerably between settings. Understanding the range of problems encountered, and the specific reasons for each medicines shortage event, may help to identify the most appropriate systems-wide responses.
South Africa’s health system is, at this point, still clearly divided between a better-resourced private sector and an overwhelmed public sector. Medicines selection and procurement processes in the two sectors are markedly different. However, in both sectors there is a dearth of publicly accessible information about the incidence and consequences of medicines shortages.
This brief report describes the medicines selection and procurement processes currently applied in South Africa’s public health sector, and then describes the nature of the medicines shortages that have been experienced in the KwaZulu-Natal provincial health services between July 2012 and June 2013. The degree to which these shortages might have been managed differently, had the recommendations developed by the International Pharmaceutical Federation Summit on Medicines Shortages been implemented, is then explored.
doi:10.4066/AMJ.2014.1932
PMCID: PMC4051355  PMID: 24944717
Medicines shortages; South Africa; public sector selection and procurement; systems-wide responses
2.  Unilateral supernumerary kidney with contra lateral hydronephrosis—a rare case report 
The Australasian Medical Journal  2014;7(5):213-217.
Supernumerary kidney is the rarest of all renal anomalies; fewer than 80 cases have been reported in the literature over the years. Supernumerary kidneys are most commonly located on the left side of the abdomen. Different pathologic conditions are reported to affect supernumerary kidneys and they may be associated with malformations of the upper urinary tract and genital tract. Because of their infrequent occurrence and reporting, they frequently cause diagnostic challenges. Here we report a case in a 14-year-old male patient of unilateral supernumerary kidney on the right side of the abdomen with multiple calculi, mal-rotation and a gross hydronephrotic left kidney.
doi:10.4066/AMJ.2014.2019
PMCID: PMC4051356  PMID: 24944718
Hydronephrosis; renal anomalies; Supernumerary kidney
3.  A qualitative study of staff perspectives of patient non-attendance in a regional primary healthcare setting 
The Australasian Medical Journal  2014;7(5):218-226.
Background
Non-attendance at health appointments reduces health service efficiency, is costly to services, and can risk patient health. Reminder systems are widely used to overcome forgetfulness, the most common reason for non-attendance; however, other factors, such as patient demographics and service accessibility, may also affect attendance rates.
Aims
There is limited primary research on the reasons for patient non-attendance in the Australian healthcare setting, although the success of preventative health initiatives requires ongoing monitoring of patients. This study aims to improve our understanding of the Australian experience by examining staff perspectives.
Method
This qualitative study explored staff perspectives of the reasons for non-attendance in a large, regional general practice super clinic, which has a low socioeconomic catchment, and serves a large Aboriginal population.
Results
The practical barriers to attendance of travel, cost, and waiting times had largely been overcome with transport provision, free medical care and responsive appointment times, but paradoxically, these were seen to devalue allocated appointments and reinforce the expectations of “on-demand” health care. For Aboriginal patients specifically, a distrust of authority, combined with poor health literacy was perceived to impact negatively on the uptake of diagnostic tests, filling of prescriptions, health monitoring, and adherence to medication.
Conclusion
The results suggest a complex interplay between poor health literacy and low patient self-worth; a funding system that encourages “five-minute medicine and prevents doctors getting to the root cause of patient problems or having the ability to provide health education.
doi:10.4066/AMJ.2014.2056
PMCID: PMC4051357  PMID: 24944719
Non-attendance; super clinic; Aboriginal; adherence; reminders
4.  Bilateral variations of brachial plexus involving the median nerve and lateral cord: An anatomical case study with clinical implications 
The Australasian Medical Journal  2014;7(5):227-231.
During the routine dissection of upper limbs of a Caucasian male cadaver, variations were observed in the brachial plexus. In the right extremity, the lateral cord was piercing the coracobrachialis muscle. The musculocutaneous nerve and lateral root of the median nerve were observed to be branching inferior to the lower attachment of coracobrachialis muscle. The left extremity exhibited the passage of the median nerve through the flat tendon of the coracobrachialis muscle near its distal insertion into the medial surface of the body of humerus. A variation in the course and branching of the nerve might lead to variant or dual innervation of a muscle and, if inappropriately compressed, could result in a distal neuropathy. Identification of these variants of brachial plexus plays an especially important role in both clinical diagnosis and surgical practice.
doi:10.4066/AMJ.2014.2070
PMCID: PMC4051358  PMID: 24944720
Brachial plexus; Lateral cord; Coracobrachialis; Median nerve
5.  Reversible lower limb deep vein thrombosis following haemotoxic snakebite—a case report 
The Australasian Medical Journal  2014;7(5):232-235.
Haemotoxic snakebite, presenting with coagulopathy and bleeding manifestations, is quite common. Thrombotic manifestations are infrequently observed. We describe the unusual case of a young male who developed deep vein thrombosis (DVT) of the left lower limb following snakebite, despite an ongoing coagulopathy. Investigations revealed leucocytosis, prolonged 20-minute whole blood clotting time (20’WBCT), prolonged prothrombin time (PT), and activated partial thromboplastin time (aPTT). Doppler study revealed thrombosis of common femoral vein, superficial femoral, and profunda femoris veins. The patient underwent two fasciotomies and received anticoagulation after which patency of the veins was restored. Doppler sonographic imaging in patients with haemotoxic snakebite who present with increasing local swelling may assist with early anticoagulation therapy that has a potential to be limb-saving.
doi:10.4066/AMJ.2014.2075
PMCID: PMC4051359  PMID: 24944721
Snake bite; DIC; DVT; Doppler ultrasound
6.  Social implications of genomic medicine: Is medicine ready? 
The Australasian Medical Journal  2014;7(5):236-237.
doi:10.4066/AMJ.2014.2099
PMCID: PMC4051360  PMID: 24944722
7.  Initial experience with GeneXpert MTB/RIF assay in the Arkansas Tuberculosis Control Program 
The Australasian Medical Journal  2014;7(5):203-207.
Background
Mycobacterium tuberculosis remains one of the most significant causes of death from an infectious agent. Rapid and accurate diagnosis of pulmonary and extra-pulmonary tuberculosis (TB) is still a great challenge. The GeneXpert MTB/RIF assay is a novel integrated diagnostic system for the diagnosis of tuberculosis and rapid detection of Rifampin (RIF) resistance in clinical specimens. In 2012, the Arkansas Tuberculosis Control Program introduced GeneXpert MTB/RIF assay to replace the labour-intensive Mycobacterium Tuberculosis Direct (MTD) assay.
Aims
To rapidly diagnose TB within two hours and to simultaneously detect RIF resistance.
Objectives
Describe the procedure used to introduce GeneXpert MTB/RIF assay in the Arkansas Tuberculosis Control Program.
Characterise the current gap in rapid M. tuberculosis diagnosis in Arkansas.
Assess factors that predict acid fast bacilli (AFB) smearnegative but culture-positive cases in Arkansas.
Illustrate, with two case reports, the role of GeneXpert MTB/RIF assay in reduction of time to confirmation of M. tuberculosis diagnosis in the first year of implementation.
Method
Between June 2012 and June 2013, all AFB sputum smearpositive cases and any others, on request by the physician, had GeneXpert MTB/RIF assay performed as well as traditional M. tuberculosis culture and susceptibilities using Mycobacteria Growth Indicator Tube (MGIT) 960 and Löwenstein-Jensen (LJ) slants. Surveillance data for January 2009–June 2013 was analysed to characterise sputum smear-negative but culture-positive cases.
Results
Seventy-one TB cases were reported from June 2012– June 2013. GeneXpert MTB/RIF assay identified all culture-positive cases as well as three cases that were negative on culture. Also, this rapid assay identified all six smear-negative but M. tuberculosis culture-positive cases; two of these cases are described as case reports.
Conclusion
GeneXpert MTB/RIF assay has made rapid TB diagnosis possible, with tremendous potential in determining isolation of TB suspects on one hand, and quickly ruling out TB whenever suspected.
doi:10.4066/AMJ.2014.1905
PMCID: PMC4052441  PMID: 24944716
Tuberculosis; GeneXpert MTB/RIF assay; AFB
8.  A study to assess the feasibility of Text Messaging Service in delivering maternal and child healthcare messages in a rural area of Tamil Nadu, India 
The Australasian Medical Journal  2014;7(4):175-180.
Background
Mobile text messaging is a potentially powerful tool for behaviour change because it is widely available, inexpensive, and instant.
Aims
To evaluate whether mobile Text Messaging Service is a feasible mode of raising knowledge regarding maternal and child health (MCH) and to explore issues related to mobile text messages as a mode of health education.
Method
A community-based intervention study was conducted from January to June 2013 in six randomly selected villages of Vellore district, Tamil Nadu. A multi-stage sampling technique was followed: 120 individuals from 120 households (30 clusters in six villages) were contacted. Data was collected using a pretested questionnaire by house-to-house visits in three phases: 1) baseline assessment of aptitude towards text messages; 2) intervention: sending MCH-related text messages; and 3) end-line assessment to evaluate the increase in knowledge level. Qualitative data regarding mobile text messages as a mode of health education was explored. Quantitative data was analysed using SPSS version 17.0 and qualitative data by Anthropac software.
Results
Of the individuals surveyed, 69.17 per cent and 52.5 per cent were “able to read” and “type and send” text messages, respectively. Seventy per cent of individuals were willing to receive health information via text messages, and 98.33 per cent believed text messages could effectively spread health messages. A significant increase in knowledge was observed following text messages. Male gender and subjects’ ability to read text messages were significantly associated. Factors related to mobile phone use include minimum economic burden, easy availability, portability, and ease of use. Factors related to mobile text messages as a mode of health message delivery include direct receipt of information, mass reach, the absence of regional language font in many handsets, and illiterate individuals being unable to read messages.
Conclusion
In rural areas, mobile text messages have the potential to deliver health messages regarding MCH.
doi:10.4066/AMJ.2014.1916
PMCID: PMC4009878  PMID: 24817911
Health education; maternal and child health; text messages
9.  Malignant melanoma of soft parts with osteoclast-rich giant cells: A rare tumour of the jejunum 
The Australasian Medical Journal  2014;7(4):181-184.
Malignant melanoma of soft parts (MMSP), first described by Franz M. Enzinger, is a rare tumour of unknown cell origin. We describe a case of a 45-year-old male who presented with a one-year history of abdominal pain, weakness, and anaemia. Computerised tomography enteroclysis showed a mass in the jejunum that was suggestive of a gastrointestinal stromal tumour. An ulceroinfiltrative lesion measuring 6.5 x 4 x 2cm was identified. Microscopy revealed typical features of MMSP with numerous osteoclasts-like giant cells. The diverse histomorphology and immunohistochemical characteristics of this case involving a rare tumour at a rare site is presented.
doi:10.4066/AMJ.2014.1970
PMCID: PMC4009879  PMID: 24817912
Malignant melanoma of soft parts; jejunum; osteoclastic giant cells
10.  A study of antibiogram of Salmonella enterica serovar Typhi isolates from Pondicherry, India 
The Australasian Medical Journal  2014;7(4):185-190.
Background
Enteric fever caused by Salmonella enterica serovar Typhi (S. Typhi) is an important public health problem in developing countries like India.1 The emergence of resistance to fluoroquinolones has reduced the therapeutic options available. Currently, the uniform laboratory interpretation of ciprofloxacin and azithromycin susceptibility remains unclear.
Aims
To study the antibiogram of S. Typhi isolates with special emphasis on in-vitro activity of ciprofloxacin and azithromycin.
Method
We evaluated the antimicrobial susceptibility pattern of 16 S. Typhi isolates from January 2012 to June 2013. We also determined by Epsilometer-test (E-test) method, the minimum inhibitory concentration (MIC) of ciprofloxacin and azithromycin against these isolates and compared them with their corresponding disc diffusion sizes.
Results
Fifteen (93.75 per cent) isolates were sensitive to chloramphenicol, 14 (87.5 per cent) were sensitive to cotrimoxazole. All isolates were resistant to nalidixic acid. MICs for ciprofloxacin ranged from 6μg/ml to 15μg/ml and corresponding zone diameters ranged from 15mm to 26mm. MIC and zone diameters for ciprofloxacin had significant negative correlation. MICs for azithromycin ranged from 3μg/ml to 24μg/ml, corresponding zone diameters ranged from 13mm to 19mm. However, MIC and zone diameters for azithromycin had no significant negative correlation.
Conclusion
The widespread emergence of resistance to fluoroquinolones and reappearance of sensitivity to firstline drugs has reinforced the need for antibiotic recycling. There is a need to have uniform laboratory testing guidelines for testing susceptibility to ciprofloxacin and azithromycin for S. Typhi isolates.
doi:10.4066/AMJ.2014.2010
PMCID: PMC4009880  PMID: 24817913
Antibiogram; ciprofloxacin; azithromycin; minimum inhibitory concentrations; S. Typhi
11.  Need for involving consumers in Nepal’s pharmacovigilance system 
The Australasian Medical Journal  2014;7(4):191-195.
In Nepal, reporting of adverse drug reactions (ADRs) occurs on a voluntary basis by doctors, pharmacists, nurses, health assistants, and other healthcare professionals. The country’s pharmacovigilance program is still in its infancy; it has limited coverage and underreporting is common. This major limitation could be reduced with consumer involvement. This report examines the necessity and benefits of consumer involvement in Nepal’s existing pharmacovigilance program, reflecting on existing examples of consumer pharmacovigilance in different countries to highlight the necessity for such a framework in Nepal.
doi:10.4066/AMJ.2014.2011
PMCID: PMC4009881  PMID: 24817914
Consumers; Nepal; pharmacovigilance
13.  Vitamin B12 deficiency presenting as pancytopenia and retinopathy in a young boy—Helicobacter pylori, a novel causative agent 
The Australasian Medical Journal  2014;7(3):143-148.
Deficiency of vitamin B12 (cobalamin) is a well-known cause of megaloblastic anaemia. It is a reversible cause of bone marrow failure and demyelinating nervous system disorder, hence early detection and prompt treatment of vitamin B12 deficiency is essential. After diagnosing vitamin B12 deficiency, tracking down its root cause is important in individualising the treatment approach. Helicobacter pylorirelated (H. pylori) B12 deficiency presenting as pancytopenia in pediatric age groups has been reported. However, vitamin B12 deficiency presenting as retinopathy in paediatric age groups has been rarely reported in the medical literature. We herein present the case of an adolescent male with pancytopenia and retinopathy, secondary to vitamin B12 deficiency-associated H. pylori infection.
doi:10.4066/AMJ.2014.1872
PMCID: PMC3973926  PMID: 24719649
Pancytopenia; retinopathy; Helicobacter pylori; vitamin B12 deficiency
14.  Acute coronary syndrome in Australia: Where are we now and where are we going? 
The Australasian Medical Journal  2014;7(3):149-156.
Background
Acute coronary syndrome (ACS) is a significant contributor to both morbidity and mortality in Australia. Generally speaking, sufferers of ACS who live in rural areas and are treated at rural hospitals have poorer outcomes than those living in metropolitan areas.
Aims
To characterise the differences in the management and outcomes of rural and metropolitan populations in the context of ACS, as well as identify factors responsible for these differences and suggest how they may be addressed.
Method
A review of the current literature surrounding ACS in Australia was undertaken. Through the MEDLINE/PubMed database a thorough search using the terms “acute coronary syndrome” and “Australia” identified 460 papers for review, excluding abstracts and adding “rural”, “metropolitan”, “reperfusion”, and “outcomes” to this search narrowed the results to 149 papers for review. Data was also extracted from the Australian Institute of Health and Welfare and other Australian government publications. The review draws on insights from both local and international resources and seeks to provide an understanding of the contemporary landscape of ACS in both rural and metropolitan Australia.
The review is broken down into three key sections:
An outline of the 2011 National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (NHF/CSANZ) guidelines and adjuvant tools used in the assessment and treatment of ACS, and to what extent these guidelines have been implemented clinically.
An exploration of the current landscape of ACS in Australia and identification of the disparities facing rural populations compared to those in metropolitan areas.
Discussion of the factors that are resulting in poorer outcomes for ACS sufferers and suggestions of novel approaches towards addressing these factors.
Conclusion
Disparities exist between the management and outcomes of rural and metropolitan populations experiencing ACS. While the causes of these discrepancies are multifactorial; the onus is on the healthcare system to effectively reduce associated morbidity and mortality. Improvements in the management of ACS may be achieved through a continued reduction in call-to-needles time via the use of remote and mobile thrombolysis services as well as improvements in in-hospital risk assessment in order to flag and investigate those at risk of ACS.
doi:10.4066/AMJ.2014.1921
PMCID: PMC3973927  PMID: 24719650
ACS; rural; metropolitan; Australia; outcomes
15.  Bilateral schizencephaly Type II 
The Australasian Medical Journal  2014;7(3):157-160.
Background
Schizencephaly is one of the most severe forms of neuronal migration defects and is an extremely rare cause of seizure disorder.
Case details
We report a case of bilateral schizencephaly (Type II) presenting as seizure disorder since birth.
Discussion
This case is rare because of the relatively benign features compared to other reported cases.
Conclusion
Compared to other cases, this patient has normal cognitive and motor functioning. Given the scant literature on schizencephaly in India’s paediatric population, this case highlights the possibility of a very rare entity associated with seizures. MRI can detect this condition.
doi:10.4066/AMJ.2014.1924
PMCID: PMC3973928  PMID: 24719651
Bilateral schizencephaly type II; seizure disorder
16.  Medicine shortages: Implications for the Australian healthcare system 
The Australasian Medical Journal  2014;7(3):161-163.
doi:10.4066/AMJ.2014.1943
PMCID: PMC3973929  PMID: 24719652
17.  Transient adrenal insufficiency and post-treatment bradycardia in scrub typhus – a case report 
The Australasian Medical Journal  2014;7(3):164-167.
Scrub typhus appears throughout the Asia-Pacific rim. This disease is known for its diverse clinical manifestations and complications. There is no literature on the association of scrub typhus with adrenal insufficiency. Relative bradycardia has been reported in scrub typhus during the febrile phase but not during convalescence. We report the case of a 45- year-old woman with scrub typhus whose blood pressure was persistently low due to acute adrenal insufficiency. Adrenal failure responded to supplementation with steroids. She also developed sinus bradycardia during the afebrile period following treatment.
doi:10.4066/AMJ.2014.1951
PMCID: PMC3973930  PMID: 24719653
Adrenal failure; scrub typhus; relative bradycardia; ACTH stimulation test
18.  Design of a new non-sterile glove-dispensing unit to reduce touch-based contamination 
The Australasian Medical Journal  2014;7(3):171-174.
Background
Despite best efforts by healthcare providers to sterilise their hands through hand washing prior to touching medical equipment and patients, bacteria are still present and can be spread through physical contact. We aimed to reduce the spread of touch-induced and airborne bacteria and virus spreading by using a touch-free glove-dispensing system that minimally exposes gloves in the box to air.
Method
The team met multiple times to undertake early prototyping and present ideas for the design. We experimented with folding gloves in varying patterns, similar to facial tissuedispensing boxes, and tried several methods of opening/closing the glove box to determine the most effective way to access gloves with the least amount of physical contact. We considered the user experience and obtained user feedback after each design iteration.
Results
Ultimately, we decided on a vertically oriented box with optional holes for dispensing a glove on the side of the box or on the bottom by means of the pull-down drawer mechanism. This system will dispense a single glove at a time to the user with the option of using a pull-down drawer trigger to decrease the likelihood of physical contact with unused gloves. Both methods dispense a single glove.
Conclusion
By reducing physical contact between the healthcare practitioner and the gloves, we are potentially reducing the spread of bacteria. This glove box design ensures that gloves are not exposed to the air in the clinic or hospital setting, thereby further reducing spread of airborne germs. This could assist in decreasing the risk of nosocomial infections in healthcare settings.
doi:10.4066/AMJ.2014.2043
PMCID: PMC3973931  PMID: 24719654
Disposable gloves; contamination; pathogens; clinic
19.  Western Australia coastal shark bites: A risk assessment 
The Australasian Medical Journal  2014;7(2):137-142.
Background
As Western Australia’s (WA) government enacts shark bite mitigation, the personal risk of shark bite in WA has not been studied.
Aims
Model the risk of large (>3m) white shark bite (Carcharodon carcharias, LWS) in southwest WA.
Method
An observational study inclusive of 1 January 1974 to 31 December 2013 was conducted. Analysis of prey abundance, location, water temperature, and water activity participation. Shark bite risk was benchmarked against serious or fatal recreational cycling crash risk in WA.
Results
Total and fatal shark bites have grown exponentially over 40 years (3 to 29 total, 0 to 7 fatal per 5 years), correlated with the 10 per cent annual growth in WA humpback whale (Megaptera novaeangliae) abundance (rtotal=0.96 95%CI 0.77–0.99, p<0.001; rfatal=0.96 95%CI 0.81-0.99, p<0.001) but not water activity participation rtotal= 0.25, 95%CI –0.45–0.76, p=0.48). LWS were implicated in 10 of 12 fatalities. Metropolitan Perth beach summer/autumn bathing less than 25m from shore in water less than 5m deep (risk lower than 1 in 20 years) is estimated to be at least 50x safer than cycling. Off-shore diving and surf sports off Perth, during winter/spring have a similar risk to cycling. Winter/spring off- shore diving south of Perth has between 3 and 11 times the cycling risk.
Conclusion
WA’s shark bite risk is likely to increase as whale abundance continues to increase off the WA coast. However, the risk to bathers less than 25m from shore in shallow water during the WA summer, is likely to remain very low, and well below the risk of other recreational activities undertaken in WA.
doi:10.4066/AMJ.2014.2008
PMCID: PMC3941575  PMID: 24611078
shark; injury; risk
20.  Shprintzen-Goldberg syndrome presenting as umbilical hernia in an Indian child 
Shprintzen-Goldberg syndrome (S-G) is a rare connective tissue disorder characterised by craniosynostosis, craniofacial dysmorphism, skeletal, cardiovascular, neurological, and other abnormalities. We herein present a case of a five-year-old Indian child who presented to our clinic with reducible umbilical hernia since birth, mental retardation, and delayed developmental milestones. After meticulous clinical examination with subsequent integration of clinical findings and investigations, we diagnosed her to possibly have Shprintzen-Goldberg syndrome. An attempt to compare the findings of our index case with the classical features as described by Greally et al. has been made. Given the rarity of this syndrome and the paucity of medical literature measuring the magnitude of this condition in the Indian population, this case serves to promote awareness of this rare entity.
doi:10.4066/AMJ.2014.1888
PMCID: PMC3941576  PMID: 24611072
Shprintzen-Goldberg syndrome; umbilical hernia; craniosynostosis; marfanoid habitus; Indian
21.  Current state of medical thromboprophylaxis in Australia 
Background
Australia has two published national guidelines for general medical thromboprophylaxis (MT), but the two differ in detail and the basis for patient selection remains uncertain. Several aspects of current guidelines are controversial, as is the proposed design of a dedicated prescribing box in the National Inpatient Medication Chart.
Aim
To discuss and comment on the current standing of medical thromboprophylaxis in Australia.
Method
We have marshalled literature known to us from our previous published research, and have applied this knowledge to discuss shortcomings, which, in our opinion, exist in current medical thromboprophylaxis practice, and to suggest solutions.
Conclusion
Australian guidelines are flawed because they are based on unsuitable evidence (incidence of subclinical thrombotic disease) and define eligibility broadly, such that about 80 per cent of patients are considered eligible. They urge that prescribers should “consider” prophylaxis without supplying an adequate basis for doing so. They do not provide grounds for assessing the balance between hazard (in the form of major bleeds) and benefit (thrombotic events avoided). Other clinical factors promoting unnecessary use of medical thromboprophylaxis include the use of age as a risk factor and proposed inclusion of a new DVT prophylaxis section in the National Inpatient Medication Chart (NIMC), which implicitly discourages non-prescription of prophylaxis.
doi:10.4066/AMJ.2014.1915
PMCID: PMC3941577  PMID: 24611073
Thromboprophylaxis; low molecular weight heparin; risk factor analysis; medical patients; guidelines
22.  Carriage prevalence of carbapenem-resistant Enterobacteriaceae in stool samples: A surveillance study 
Background
With more people being exposed to antibiotics, intestinal microflora faces constant pressure of antibiotic selection, which has resulted in the emergence of multidrug resistant strains. This may pose a severe problem as intestinal Enterobacteriaceae members are commonly implicated in human infections.
Aims
This surveillance study was undertaken to investigate the carriage of carbapenem-resistant Enterobacteriaceae (CRE) in the gastrointestinal tract among patients attending the outpatient clinic in a tertiary care center of East Delhi, India.
Method
We performed a prospective surveillance study to screen 242 Enterobacteriaceae isolates for carbapenemase production from the stool samples of 123 outpatients attending a tertiary care hospital in East Delhi over a four-month period.
Results
Twenty-four (9.9 per cent) isolates demonstrated carbapenemase activity among 242 screened Enterobacteriaceae isolates. Four stool samples had two isolates of different species, both eliciting this feature and therefore indicating presence of multiple carbapenem-resistant Enterobacteriaceae (CRE) isolates in a single sample.
Conclusion
Screening for carriage of CRE in stools of patients undergoing elective or emergency gastrointestinal surgical procedures, with haematological malignancies taking chemotherapy, or those planned for bone marrow transplantation can guide clinicians about gut colonisation of multidrug-resistant Enterobacteriaceae as these groups of patients are at risk of possible endogenous infection.
doi:10.4066/AMJ.2014.1926
PMCID: PMC3941578  PMID: 24611074
Carbapenem resistant Enterobacteriaceae; gut colonisation; prophylactic antibiotic
23.  Rosai-Dorfman disease: A rare clinico-pathological presentation 
Rosai-Dorfman disease (RDD) is also known as Sinus Histiocytosis with Massive Lymphadenopathy (SHML). It is a rare, benign, self-limiting disease of phagocytic histiocytes affecting a young age group presenting with massive painless cervical lymphadenopathy. RDD has nodal and also extra-nodal involvement with episodes of exacerbation and remissions, whose aetiology remains poorly elucidated. It is highly variable in its clinical presentation and response to treatment. Its treatment is poorly defined but the prognosis is usually favourable. Here we are reporting a rare, unusual clinical presentation of cervical lymphadenopathy and nasal mass diagnosed as RDD with cyto-histopathological correlation. Only a few such cases have been reported in the literature. We also emphasise that clinicians and pathologists should always be aware of RDD in making a differential diagnosis of cervical lymphadenopathy.
doi:10.4066/AMJ.2014.1931
PMCID: PMC3941579  PMID: 24611075
Rosai-Dorfman Disease; cervical lymphadenopathy; histiocytes; emperipolesis
24.  Antibiotic screening of urine culture as a tool for interal quality audit 
Background
Microbiologic culture of urine is an important component in the diagnosis of urinary tract infections (UTI). However, confounding factors like the patient’s current history of antibiotic usage can affect the interpretation of urine culture results.
Aims
This study was undertaken to find out the occurrence of unreported antibiotic consumption prior to urine culture and its clinical consequences.
Method
In this descriptive study conducted from February to August 2013, we tested consecutive urine specimens for the presence of antibiotics with a modified urine antibacterial substance assay (UABA) and compared the results obtained with the accuracy of antibiotic data entry on the accompanying request forms. In addition, the consequences of culturing urine specimens with incomplete antibiotic history received in the laboratory were investigated.
Results
Out of 2,040 urine specimens, 721 (35.34 per cent) were UABA positive. Comparison of antibiotic screening of urine with antibiotic data entry from request forms showed 1,299 (63.68 per cent) true-negative, 38 (1.86 per cent) true- positive, 20 (0.98 per cent) false-negative, and 683 (33.48 per cent) false-positive results. The sensitivity and specificity of this test were 65.52 per cent and 65.54 per cent, respectively. The positive and negative predictive values were 5.27 per cent and 98.48 per cent, respectively. The UABA had a positive diagnostic likelihood ratio of 1.901.
Conclusion
This internal audit demonstrates how the accurate history of current antibiotic usage in the request forms impacts the interpretation of urine culture results.
doi:10.4066/AMJ.2014.1956
PMCID: PMC3941580  PMID: 24611076
Antibiotic screening; internal audit; Antibiotic History; Urine culture
25.  The future of primary healthcare in Australia: Where to from here? 
doi:10.4066/AMJ.2014.1959
PMCID: PMC3941581  PMID: 24611077

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