New Delhi metallo-beta-lactamase-producing Enterobacteriaceae in an Australian child who had not travelled overseas, CC Blyth, L Pereira, N Goire

Tags: Australia, NHMRC, National Health and Medical Research Council, cancer, Med J Aust, New Delhi, Klebsiella pneumoniae, conditions, pregnancy, disease burden, breast cancer, National Stroke Foundation, Medical Research, gram-negative bacteria, clinical guidelines, alcohol consumption, MJA, Gerry Harnett, Macquarie Neurosurgery, J Neurol Neurosurg Psychiatry, open access journals, Laboratory Standards Institute, Donald Payne, David Speers, Zoy Goff, Directory of Open Access Journals, open access, communication, communication disorders, speech pathology services, NHMRC research funding, Linkage grants, guidelines, Von Dincklage, ARC Discovery, subarachnoid haemorrhage, swallowing disorders, funding agencies, Australian Research Council, musculoskeletal conditions, Microbiology staff, research funding, Department of Microbiology, PathWest Laboratory Medicine WA, University of Adelaide, William J Milford, Department of Obstetrics and Gynaecology, Townsville Hospital, clinical research, Clinical academic pathways, Harris A Eyre, clinical academic, Australian Medical Association, Australian Government Department, Emergency Department, clinical research article, academic medicine, Willcox S. Creating, alcohol dependence, urinary tract infection, Enterobacteriaceae, Princess Margaret Hospital for Children, Jeffrey Beall, Open Access Scholarly Publishers Association, the Journal, relevant medical history, Australian child, Therapeutic Goods Administration Advisory Committees on Prescribing Medicines, pregnant women, Catherine Joyce, Rob D Mitchell, University of Western Australia, National Institute for Health and Care Excellence, Christopher C Blyth
Content: Letters
New Delhi metallo-betalactamase-producing Enterobacteriaceae in an Australian child who had not travelled overseas TO THE EDITOR: The editorial by Looke and colleagues in the 18 March 2013 issue of the Journal highlighted the increasing threat of gram-negative resistance.1 Since its description in 2009,2 gram-negative bacteria carrying the gene for New Delhi metallo-beta-lactamase-1 (NDM-1) production have been observed globally. To date, a small number of cases have been reported in adults in Australia.3-5 In all cases, patients travelled to the Indian subcontinent; many required hospitalisation for their infection. We report the first case of NDM-1producing Enterobacteriaceae in a young infant who had not travelled outside Australia. An Australian-born 3-week-old boy presented to hospital in 2013 with a 4-day history of cough, rhinorrhoea and vomiting. His mother had visited Pakistan and Afghanistan in 2011 and 2012, respectively. The mother had no relevant medical history and had not attended hospitals in either country. She had lived in Australia exclusively during pregnancy. Culture of a clean-catch urine sample grew more than 108 colonyforming units (CFU) per litre of Klebsiella pneumoniae (amoxycillin resistant, otherwise susceptible). The child was diagnosed with a urinary tract infection and treated with ceftriaxone and gentamicin followed by oral combined trimethoprim and sulfamethoxazole (co-trimoxazole). The child's symptoms resolved and imaging showed no structural anomaly. The child re-presented at 5 weeks of age with irritability and vomiting. A urine sample was taken, and the culture grew > 108 CFU/L of Enterobacter
cloacae. Susceptibility testing was performed using agar dilution, Vitek2 and Etests (bioMйrieux). Using Clinical and Laboratory Standards Institute breakpoints, the isolate was resistant to all -lactam antibiotics, including meropenem, aminoglycosides, quinolones, cotrimoxazole and nitrofurantoin. The minimum inhibitory concentrations to colistin, tigecycline and fosfomycin were < 2 mg/L, < 4 mg/L and < 16 mg/L, respectively. polymerase chain reaction-based investigation of -lactamase production provided positive results for blaNDM-1 and blaCTX-M genes. The child was successfully treated with oral fosfomycin (100 mg/kg/day). This case highlights the emerging impact of NDM-1-producing bacteria. Given that the likely source was the mother or another household contact, this is an example of vertical or horizontal transmission in a country with low community prevalence of NDM1-producing bacteria. In addition to an increased risk for patients previously receiving medical care overseas or returning from countries where there is a high risk of infection with gram-negative bacteria producing NDM-1, their children and household contacts are also at increased risk. Christopher C Blyth Paediatric infectious diseases Physician and Clinical Microbiologist1,2 Lynette Pereira Microbiology Registrar2 Namraj Goire Senior Scientist3 1 School of Paediatrics and Child Health, University of Western Australia, Perth, WA. 2 PathWest Laboratory Medicine WA, Princess Margaret Hospital for Children, Perth, WA. 3 Department of Microbiology, PathWest Laboratory Medicine WA, QEII Medical Centre, Perth, WA. [email protected] Acknowledgements: We thank Tony Keil. Donald Payne, Paula Holmes, Gerry Harnett, David Speers, Zoy Goff, Infection Control and Microbiology staff at Princess Margaret Hospital for Children and King Edward Memorial Hospital for Women. Competing interests: No relevant disclosures. doi: 10.5694/mja13.11053 1 Looke DF, Gottlieb T, Jones CA, Paterson DL. Gram-negative resistance: can we combat the coming of a new "Red Plague"? Med J Aust 2013; 198: 243-244.
The `publish or perish' culture is perhaps one important factor cultivating this contamination of scientific literature Xu et al
2 Yong D, Toleman MA, Giske CG, et al. Characterization of a new metallo-betalactamase gene, bla(NDM-1), and a novel erythromycin esterase gene carried on a unique genetic structure in Klebsiella pneumoniae sequence type 14 from India. Antimicrob Agents Chemother 2009; 53: 5046-5054. 3 Poirel L, Lagrutta E, Taylor P, et al. Emergence of metallo--lactamase NDM-1-producing multidrug-resistant Escherichia coli in Australia. Antimicrob Agents Chemother 2010; 54: 4914-4916. 4 Rogers BA, Sidjabat HE, Silvey A, et al. Treatment options for New Delhi metallo-beta-lactamase-harboring enterobacteriaceae. Microb Drug Resist 2013; 19: 100-103. 5 Sidjabat H, Nimmo GR, Walsh TR, et al. Carbapenem resistance in Klebsiella pneumoniae due to the New Delhi metallo-lactamase. Clin Infect Dis 2011; 52: 481-484. Caveat emptor: the corruption of open access scientific publishing TO THE EDITOR: Since our publication in the Journal,1 it would seem that a simple case report leadauthored by an intern has rendered him a virtual expert in the fields of infectious diseases, cell biology and cardiology, just to name a few. Or at least, one could be led to believe so with the sheer number of enticing invitations received in our corresponding author's inbox (about five per week), inviting his"eminent self"to write journal articles, sit on editorial boards, and speak at international cardiology conferences in far-reaching and exotic locations such as Guangzhou and Dubai.2 Such is how the rapidly expanding and controversial entity of"predatory publishing"is luring unsuspecting authors into submitting their research -- either legitimate or decidedly sub-par -- to a host of open access journals with more pecuniary than academic interest.3 Once copyright is transferred, an invoice of thousands of dollars may be bestowed before publication can proceed. Jeffrey Beall, academic librarian and curator of a growing"black list"of these journals, lists 285 such publications
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on his website, Scholarly Open Access (http://www.scholarlyoa. com), at last count. This contrasts a corresponding"white list"compiled by industry directories such as Open Access Scholarly Publishers Association and Directory of Open Access Journals. The"publish or perish"culture is perhaps one important factor cultivating this contamination of scientific literature. Less scrupulous authors looking to"pad"their curriculum vitae may be drawn to the lacklustre peer review or disinterest in true scholarly value of these journals. An exposй recently published in Science documented a 70% acceptance rate of a spoof paper filled with methodological and ethical flaws, outlandish results and poor grammar, which was submitted to a sample of open access journals purporting peer review processes.4 Disappointingly, this included 45% of journals on the putative"white list". Despite these issues, many strongly believe that the revolution of open access publishing represents the future of academia and a necessary counterpoint to "luxury journals", by publishing work according to quality rather than arbitrary caps, and increasing the accessibility of scientific information worldwide.5 In this context, we seek only to remind the open access consumer of the ageold adage,"caveat emptor". Lileane Liang Xu Resident1 Anthony Minh Tien Chau Registrar2 1 Orthopaedics, Liverpool Hospital, Sydney, NSW. 2 Neurosurgery, Macquarie Neurosurgery, Sydney, NSW. [email protected] Competing interests: No relevant disclosures. doi: 10.5694/mja13.00082 1 Chau AM, Xu LL, Fairhall JM, et al. Brain abscess due to Propionibacterium propionicum in Eisenmenger syndrome. Med J Aust 2012; 196: 525-526. 2 Gransalke K. Fake conferences. Lab Times 2009; (6): 6-7. 3 Butler D. Investigating journals: the dark side of publishing. Nature 2013; 495: 433-435. 4 Bohannon J. Who's afraid of peer review? Science 2013; 342: 60-65. 5 Schekman R. How journals like Nature, Cell and Science are damaging science. The Guardian 2013; 10 Dec. http://www. theguardian.com/commentisfree/2013/ dec/09/how-journals-nature-science-celldamage-science (accessed Feb 2014).
It's time for clinical guidelines to enter the digital age TO THE EDITOR: We agree with Olver and Von Dincklage on the need to move towards digital guidelines.1 The National Stroke Foundation (NSF) has been developing guidelines for approval by the National Health and Medical Research Council (NHMRC) for the past 8 years. By the time a guideline has been developed, submitted to the NHMRC and then released (a process that takes about 2 years), there will be new evidence that will change some recommendations (eg, new evidence for blood pressure management in haemorrhagic stroke is not captured in current guidelines2). While we are unaware of evidence that outdated guidelines are a barrier to the implementation of evidence-based care, clinicians express concern about guidelines that are not up-to-date and are likely to affect patient care.3 We agree that better use of electronic platforms is both inevitable and beneficial for the reasons outlined by Olver and Von Dincklage.1 Online platforms also provide the vehicle for international collaboration and sharing of information with other guideline developers, thus reducing the time and cost of guideline development while improving transparency and quality. The NSF is using a staged approach to transition its guidelines onto a wiki-based platform. Initially, we will move the current NHMRC-approved guidelines into an online"document". Until NHMRC processes for approval of a wiki-based guideline are released, the entire guideline will need to be reviewed and approved by the NHMRC in the paper-based form, and then migrated to the online platform for implementation. This will be a costly and complex process, but it is necessary until a nationally accepted standard for
Changes in behavioural risk factors are effective in preventing both pre- and postmenopausal breast cancer, including in women at high genetic risk Schultz
developing online guidelines is released. national standards specifically for digitally produced and maintained guidelines are urgently required. Richard I Lindley Moran Foundation for Older Australians Professor of Geriatric Medicine1 Richard G Larkins President2 Erin Lalor Chief Executive Officer2 1 Sydney Medical School, Westmead Hospital, University of Sydney, Sydney, NSW. 2 National Stroke Foundation, Melbourne, VIC. [email protected]
Competing interests: No relevant disclosures. doi: 10.5694/mja13.00245
1 Olver IN, Von Dincklage JJ. It is time for clinical guidelines to enter the digital age. Med J Aust 2013; 199: 569-570.
2 Anderson CS, Heeley E, Huang Y, et al; INTERACT2 Investigators. Rapid bloodpressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med 2013; 368: 2355-2365.
3 Phan TG, Thrift A, Cadilhac D, Srikanth V.
A plea for the use of systematic review
methodology when writing guidelines and
timely publication of guidelines [letter].
Intern Med J 2012; 42: 1369-1371.

The utility of genetics in inherited cancer TO THE EDITOR: In their perspective article, Winship and Tucker highlight the possibility of preventing genetic breast cancer, a triumph of modern medicine.1 However less than 5% of breast cancer is caused by genetic mutation.2 The vast majority of breast cancers are not genetic. Compared with cases of breast cancer with genetic causes, many more cases have environmental causes, including lack of physical activity, overweight and obesity, and alcohol consumption. These are powerful effects: for example, cohort and case­control studies suggest that walking 3­4 hours per week may reduce the risk of breast cancer by around 30%.3 Smoking is also an important cause of breast cancer, particularly smoking before a woman's first birth.4 Effective implementation of established health promotion strategies will prevent breast cancer.3 Changes in behavioural risk factors are effective in preventing both pre- and postmenopausal breast cancer, including in women
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at high genetic risk.3 These strategies complement screening mammography and targeted strategies for the 1% of women at high risk.3 Women should be informed that these common behavioural risk factors increase risk of breast cancer, in addition to their effects on other chronic diseases.5 Population-based health promotion strategies should highlight reduction in breast cancer risk from healthy lifestyles. Rosalie Schultz Senior Medical Officer Regional Health Services Division, Central Australian Aboriginal Congress, Alice Springs, NT. [email protected]
Competing interests: No relevant disclosures. doi: 10.5694/mja13.00187
1 Winship IM, Tucker K. The utility of genetics in inherited cancer. Med J Aust 2013; 199: 644.
2 Cancer Australia. Clinical best practice. Breast cancer. Familial risk assessment FRABOC. http://canceraustralia.gov.au/clinicalbest-practice/gynaecological-cancers/ familial-risk-assessment-fra-boc (accessed Nov 2013).
3 Coyle YM. Lifestyle, genes, and cancer. In: Verma M, editor. Cancer epidemiology. Vol. 2: modifiable factors. Toolwa, NJ: Humana Press, 2009: 25-56.
4 Gaudet MM, Gapstur SM, Sun J, et al. Active smoking and breast cancer risk: original cohort data and meta-analysis. J Natl Cancer Inst 2013; 105: 515-525.
5 Royal Australian College of General
Practitioners. Breast cancer. In: Guidelines for
preventive activities in general practice. 8th
ed. http://www.racgp.org.au/your-practice/
guidelines/redbook/early-detection-of-
cancers/breast-cancer (accessed Nov
2013).

Growing the clinical academic workforce: the case for structured academic training programs for junior doctors TO THE EDITOR: In response to an emerging mismatch between supply and demand for academic clinicians,1 several organisations have highlighted the potential value of an explicit clinical academic training pathway for Australian medical graduates.1,2 An initiative of this nature would not only increase educational capacity, but would also help realise the aspirations of the McKeon Review of Health and Medical Research -- to achieve and sustain health care excellence
through training and retaining a world-class medical research workforce.3 While a longitudinal academic training program spanning different specialties is unlikely to eventuate in the short term, supporting prevocational trainees to undertake research and teaching activities is a critical first step. Interest in academic medicine wanes during the early postgraduate years, and targeted initiatives are needed to break down the barriers to clinical academic careers.1,4 An instructive example is the academic stream of the United Kingdom's Foundation Programme for medical graduates, which supports around 450 junior doctors per year to develop skills in research, teaching and leadership. Academic activities are "protected"and take place either concurrently or in sequence with clinical roles. A variety of projects (from lab-based research to health leadership initiatives) are on offer, and all participants have access to supervision, mentoring and academic infrastructure. The program was strongly commended in a recent evaluation report.5 The UK academic Foundation Programme provides a model that could be adapted for Australia. Although there are important barriers to reform (including geographical diversity in models of prevocational training; competing clinical service demands; suboptimal integration between universities, health services and funding partners; and resource constraints), the impending introduction of activity-based funding for teaching, training and research might provide an opportunity to tackle some of these problems. The success of the Australian General Practice Training program's academic rotation shows that these kinds of initiatives are feasible in the local context. Patients, senior clinicians and trainees all stand to benefit from a stronger clinical academic workforce. Although there are other important barriers to the recruitment and retention of
Patients, senior clinicians and trainees all stand to benefit from a stronger clinical academic workforce Eyre et al
academic clinicians (including demands of clinical practice, job insecurity and pay inequity), supporting junior doctors to undertake academic activities is a strategy worthy of strong consideration.
Harris A Eyre PhD Candidate1
Rob D Mitchell Registrar2
William J Milford Senior Registrar3 1 Discipline of Psychiatry, University of Adelaide, Adelaide, SA. 2 Emergency Department, Townsville Hospital, Townsville, QLD. 3 Department of Obstetrics and Gynaecology, Mater Mother's Hospital, Brisbane, QLD. [email protected]
Acknowledgements: We thank Nick Webb and Catherine Joyce for their input to and advice about this letter.
Competing interests: No relevant disclosures. doi: 10.5694/mja13.00204
1 Willcox S. Creating and sustaining the next generation of the clinical academic workforce: issues and strategies for Australia and New Zealand. A discussion paper prepared for Medical Deans Australia and New Zealand. 2011. http://emobilise.com. au/uploads/Investment%20Theme%20 Readings%20Library/Clinical%20 Academic%20Workforce%20Creating%20 and%20Sustaining%20the%20Next%20 Generation%20August%202011.pdf (accessed Jan 2014).
2 Australian Medical Association. Clinical academic pathways in medicine ­ 2013. https://ama.com.au/position-statement/ clinical-academic-pathways-medicine-2013 (accessed Dec 2013).
3 Australian Government Department of Health. Strategic review of health and medical research: better health through research. Canberra: Commonwealth of Australia, 2013. http://www.mckeonreview. org.au/downloads/Strategic_Review_of_ Health_and_Medical_Research_Feb_2013Final_Report.pdf (accessed Feb 2014).
4 Straus SE, Straus C, Tzanetos K; International Campaign to Revitalise Academic Medicine. Career choice in academic medicine: systematic review. J Gen Intern Med 2006; 21: 1222-1229.
5 Collins J. Foundation for excellence: an
evaluation of the foundation programme.
London: Medical Education England, 2011.
http://www.mee.nhs.uk/pdf/401339_MEE_
FoundationExcellence_acc_FINAL.pdf
(accessed Feb 2014).

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Changes in alcohol consumption in pregnant Australian women between 2007 and 2011 TO THE EDITOR: I refer to the article by Cameron and colleagues.1 As a member of successive Therapeutic Goods Administration Advisory Committees on Prescribing Medicines in Pregnancy (1989­2005), I thoroughly endorse the authors' concerns about the teratogenic effects of excessive alcohol consumption during pregnancy, and support wholeheartedly the advice that, ideally, avoiding alcohol during pregnancy is best. However, I am concerned that, as stated in my submission to the National Health and Medical Research Council (NHMRC),2 the current guidelines rely on poorly designed studies to support the implication that there are residual risks to the fetus from a pregnant woman consuming alcohol at a
low level, by advising:"The risk to the fetus from low level drinking is likely to be low".3 A large recent prospective Cohort study conducted in the United Kingdom did not produce evidence of harm with lowlevel use.4 When women are provided with advice after intermittent low-level exposure to alcohol in pregnancy, they must also be given reassurance to avoid the prospect of unnecessary anxiety or contemplation of unwarranted termination. Significantly, peak overseas health Advisory Groups, including the National Institute for Health and Care Excellence in the UK, and obstetric organisations in the United States and Canada have expressed concern about the potential for unwarranted terminations being contemplated by women following low-level alcohol use in pregnancy. The Society of Obstetricians and Gynaecologists of Canada have specifically published reassuring advice:"Health care
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providers should advise women that low-level consumption of alcohol in early pregnancy is not an indication for termination of pregnancy".5 The time is overdue for the NHMRC to provide a similar statement to provide greater reassurance to women who have consumed low levels of alcohol during pregnancy. Ronald P Batagol Obstetric Drug Information Consultant Melbourne, VIC. [email protected] Competing interests: No relevant disclosures. doi: 10.5694/mja13.00234 1 Cameron CM, Davey TM, Kendall E, et al. Changes in alcohol consumption in pregnant Australian women between 2007 and 2011. Med J Aust 2013; 199: 355-357. 2 Batagol R. Alcohol guidelines public consultation and submissions -- submission 44. Canberra: National Health and Medical Research Council, 2008. http://www.nhmrc. gov.au/your-health/alcohol-guidelines/ alcohol-guidelines-public-consultation-andsubmissions (accessed Mar 2014). 3 National Health and Medical Research Council. Australian guidelines to reduce health risks from drinking alcohol. Canberra: NHMRC, 2009. http://www.nhmrc.gov.au/ guidelines/publications/ds10 (accessed Mar 2014). 4 Kelly Y, Iacovou M, Quigley MA, et al. Light drinking versus abstinence in pregnancy -- behavioural and cognitive outcomes in 7-year-old children: a longitudinal cohort study. BJOG 2013; 120: 1340-1347. 5 Carson G, Cox LV, Crane J, et al. Alcohol use and pregnancy consensus guidelines. J Obstet Gynaecol Can 2010; 32 (8 Suppl 3): S1-S31. Prevention of fetal alcohol spectrum disorders must include maternal treatment TO THE EDITOR: There is an increased focus on fetal alcohol spectrum disorders (FASD) in Australia with population prevention strategies and innovative work to improve detection and diagnosis of FASD, particularly in Indigenous communities.1 However, there has been insufficient focus on treatment for women with alcohol dependence, and this is where risk of harm is highest. Despite evidence to suggest a decline in the number of Australian women drinking during pregnancy, the proportion drinking at high levels remains unchanged and treatment coverage for this group
poor.2 It is estimated that 3.7% of Australian women will meet the criteria for an alcohol use disorder in a given year,3 yet only 8.5% will obtain any treatment.4 Given that only a minority of these women will be pregnant, it suggests even poorer coverage for this group. Antenatal care is also compromised. Hospital data suggest that women with alcohol use disorders during pregnancy present late to antenatal care and are often unbooked at delivery.5 Thus, targeted interventions and treatments are urgently required. A lack of ambulatory services and dedicated detoxification facilities that will admit pregnant women, services that accommodate women with other children and the substantial stigma associated with alcohol use in pregnancy all remain significant barriers to treatment. Unlike opioid substitution therapy, no pharmacological interventions, other than vitamins, are available for pregnant women who are alcohol dependent. Effective psychosocial approaches are also not routinely available. There is a need for high-quality intervention research.5 In addition to public health initiatives to prevent FASD, identification and treatment of alcohol dependence in pregnancy must be improved. Midwives, obstetricians and other professionals in primary and Acute Care need appropriate training in routine screening for alcohol use. Availability and access to services need to be improved, with clear pathways to care. We know outcomes are far worse for women with alcohol dependence and their babies alike, with higher than expected rates of morbidity and mortality in both groups.1 Alcohol dependence is a chronic relapsing disorder, and more needs to be done to treat women as a component of any effort to prevent FASD. Without this, prevention campaigns are neglecting one of the most vulnerable and high-risk groups in society; surely we can and must do much better than that.
When women are provided with advice after intermittent low-level exposure to alcohol in pregnancy, they must also be given reassurance Batagol
Lucy Burns Associate Professor1
Courtney Breen Research Fellow1
Adrian J Dunlop Area Director of Drug and Alcohol Clinical Services2 1 National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW. 2 Hunter New England Local Health District, NSW Health, Newcastle, NSW. [email protected]
Acknowledgements: The National Drug and Alcohol Research Centre at the University of NSW is supported by funding from the Australian Government. Courtney Breen has received funding from the Australian Government's Substance Misuse Prevention and Service Improvement Grants fund.
Competing interests: No relevant disclosures. doi: 10.5694/mja13.00019
1 Burns L, Elliott EJ, Black E, Breen C, editors. Fetal alcohol disorders in Australia: an update. Monograph of the Intergovernmental Committee of Drugs Working Party of Fetal Alcohol Spectrum Disorders. June 2012. http://www.nationaldrugstrategy.gov.au/ internet/drugstrategy/publishing.nsf/Conte nt/55FEF3DF7E89405FCA257BB0007DF141 /$File/FASD-2012-Monograph.pdf (accessed Feb 2014).
2 Cameron CM, Davey TM, Kendall E, et al. Changes in alcohol consumption in pregnant Australian women between 2007 and 2011. Med J Aust 2013; 199: 355-357.
3 Teesson M, Hall W, Slade T, et al. Prevalence and correlates of DSM-IV Alcohol Abuse and dependence in Australia: findings of the 2007 National Survey of Mental Health and Wellbeing. Addiction 2010; 105: 2085-2094.
4 Australian Institute of Health and Welfare. Alcohol and other drug treatment services in Australia 2009­10: report on the National Minimum Data Set. Canberra: AIHW, 2011. (AIHW Cat. No. HSE 114; Drug Treatment Series No. 14.) https://www.aihw.gov. au/publication-detail/?id=10737420496 (accessed Mar 2014).
5 Smith EJ, Lui S, Terplan M. Pharmacologic
interventions for pregnant women enrolled
in alcohol treatment. Cochrane Database Syst
Rev 2009; (3): CD007361.

Pathways to enhancing the quality of stroke care through national data monitoring systems for hospitals TO THE EDITOR: Stroke care can only benefit from an integrated system for monitoring the quality of hospital care. However, in Cadilhac and colleagues' article,1 there appears a significant omission regarding the importance of correctly categorising stroke subtypes. Categorising and including stroke subtypes is important, as the term stroke is poorly defined in the literature,2 and the advent
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of thrombolytic treatment has focused global research and public awareness campaigns on ischaemic events with the emphasis being on time to treatment and the provision of care within stroke units. The result of this has been a plethora of literature that identifies stroke solely with ischaemic events. The effect of this narrowed definition has been to focus attention and guidelines on ischaemic stroke, thereby disengaging other stroke subtypes that are generally not managed in mainstream stroke units, including haemorrhagic events and aneurysmal subarachnoid haemorrhage (aSAH), from being a"stroke". To avoid the misrepresentation of stroke as primarily an ischaemic event, haemorrhagic events need to be acknowledged in the literature. A clear context statement or definition of stroke will remove the ambiguity from the inclusion or exclusion of haemorrhagic events, particularly aSAH, in research and more significantly, in national data monitoring systems. While the paper highlights that "much can be gained from bringing together diverse groups with a vested interest in a single, clinical population", the population of haemorrhagic stroke patients must first be recognised and included. Linda J Nichols Lecturer and Unit Coordinator, Neuroscience Nursing1 Lindsay Smith Lecturer2 Penny L Allen Research Fellow3 1 School of Health Sciences, University of Tasmania, Hobart, TAS. 2 School of Health Sciences, University of Tasmania, Launceston, TAS. 3 Rural Clinical School, University of Tasmania, Burnie, TAS. [email protected] Competing interests: No relevant disclosures. doi: 10.5694/mja13.00148 1 Cadilhac DA, Moss KM, Price CJ, et al. Pathways to enhancing the quality of stroke care through national data monitoring systems for hospitals. Med J Aust 2013;199: 650-651. 2 Sacco RL, Kasner SE, Broderick JP, et al; American Heart Association Stroke Council, Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular and Stroke Nursing; Council on Epidemiology and Prevention; Council on Peripheral Vascular Disease; Council on Nutrition, Physical Activity and Metabolism. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart
Association/American Stroke Association.
Stroke 2013; 44: 2064-2089.

IN REPLY: We thank Nichols and colleagues for highlighting the heterogeneity of conditions underlying acute stroke, and the associated variability in risk factors, prognosis and management. The management of haemorrhagic forms of stroke, namely spontaneous intracerebral haemorrhage (ICH) and subarachnoid haemorrhage (SAH), has traditionally been focused on neurosurgical intervention to decompress the mass effect of the haematoma, relieve intracranial pressure, and reduce the risk of re-bleeding. The Australian Stroke Clinical Registry (AuSCR) and the National Stroke Foundation national audit include cases of ICH since care quality and outcomes may differ for patients with ICH compared with those with ischaemic stroke.1 Since few ICH cases require neurosurgery,2 evidence for better medical management of ICH is needed (eg, early intensive blood pressure lowering treatment).3 Therefore, ICH must continue to be part of national monitoring of stroke care. Current national monitoring excludes cases of SAH since it remains firmly a "neurosurgical"condition. A separate national SAH registry to monitor process of care may be warranted, given that epidemiological data show stable rates and outcomes for the disease over recent decades.4,5 Stroke is a complex disease for which continued efforts to monitor and improve care provide the best opportunity to improve outcomes. Dominique A Cadilhac Head1,2 Craig S Anderson Senior Director,3 and Professor4 1 Translational Public Health and Evaluation UNIT, Stroke and Ageing Research, Southern Clinical School, Monash University, Melbourne, VIC. 2 Public Health, Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne, VIC. 3 Neurological and Mental Health Division, The George Institute for Global Health, Sydney, NSW. 4 Stroke Medicine and Clinical Neuroscience, University of Sydney, Sydney, NSW. [email protected] Competing interests: Dominique Cadilhac is the data custodian for the AuSCR and supervises the analysis of National Stroke Foundation audit data. Craig Anderson is the Chair of the AuSCR. doi: 10.5694/mja14.00044 1 Sheedy R, Bernhardt J, Levi CR, et al. Are patients with intracerebral haemorrhage disadvantaged in hospitals? Int J Stroke 2013;
A separate national subarachnoid haemorrhage registry to monitor process of care may be warranted Cadilhac et al
21 Nov [Epub ahead of print]. doi: 10.1111/ ijs.12223.
2 Mendelow AD, Gregson BA, Rowan EN, et al; STICH II Investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet 2013; 382: 397-408.
3 Anderson CS, Heeley E, Huang Y, et al; INTERACT2 Investigators. Rapid bloodpressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med 2013; 368: 2355-2365.
4 de Rooij NK, Linn FH, van der Plas JA, et al. Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends. J Neurol Neurosurg Psychiatry 2007; 78: 1365-1372.
5 Worthington JM, Goumas C, Jaeger M, et al.
Observational Australian study investigating
the epidemiology, outcomes and
management of non-traumatic subarachnoid
haemorrhage (OASIS study): attack rates,
admission rates and outcomes [abstract].
Int J Stroke 2012; 7 Suppl 1: 4-5. http://
onlinelibrary.wiley.com/doi/10.1111/j.1747-
4930.2012.00907.x/pdf (accessed Feb
2014).

Proportionate research funding based on relative burden of conditions of communication and swallowing TO THE EDITOR: Bourne and colleagues1 describe an important disconnect between the relative burden of musculoskeletal conditions and investment in clinical research in Australia. A similar disproportionate allocation of funding is looming in conditions of communication and swallowing, which affect one in seven Australians.2 These disorders typically concern vulnerable populations of early development and ageing, including those with autism, stroke and neurodegeneration. To examine the alignment between disease burden and research investment, we conducted a database search of National Health and Medical Research Council (NHMRC) and Australian Research Council (ARC) funding over a 10-year period (2004­2013), focusing on grants for research into communication and swallowing disorders.3 Grants included those for people support, projects, programs, and linkage and discovery. Of the 12 000 grants awarded by the NHMRC and ARC, 154 met the criteria for
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communication and swallowing disorders. The monetary value of these grants totalled about $61 million (1.1% of all funding awarded). Funding for hearing impairment research (42%) represented the bulk of the grants, followed by funding for stuttering (17%), language (16%), speech (7%), literacy (3%) and swallowing (3%). Mixed-focus research accounted for 12% of funding. In acknowledgement of the significant burden of communication and swallowing conditions in Australia, the federal government has initiated a Senate inquiry into the health, social and economic impact of these conditions.4 The inquiry's remit is to investigate (i) the prevalence of communication and swallowing disorders; (ii) the availability, adequacy and projected demand of speech pathology services provided by all sectors (public and private);
and (iii) the social and economic cost of failing to treat these conditions. These data, along with studies by Bourne and colleagues1 and Mitchell and colleagues,5 signal the need for further consideration of the way in which medical and health dollars are allocated by Australia's premier funding agencies. The Senate inquiry may offer an opportunity to explore the role of proportionate research funding based on burden of disease within a group of disorders that are vastly underrepresented in the current grant environment. Adam P Vogel Senior Research Fellow Sarah E Plant Speech Pathologist Speech Neuroscience Unit, University of Melbourne, Melbourne, VIC. [email protected] Competing interests: Adam Vogel is funded by NHMRC Early Career Fellowship and ARC Discovery and Linkage grants.
conditions of communication and swallowing . . . affect one in seven Australians Vogel et al
doi: 10.5694/mja13.00244
1 Bourne AM, Whittle SL, Richards BL, et al. The scope, funding and publication of musculoskeletal clinical trials performed in Australia. Med J Aust 2014; 200: 88-91.
2 Speech Pathology Australia. Speech pathologists urge Australians to `tell their story'. Aug 2012. http://www. speechpathologyaustralia.org.au/news-andevents/speech-pathology-week (accessed Dec 2013).
3 National Health and Medical Research Council. The last ten years of NHMRC research funding dataset 2004­2013 [database]. Aug 2013. http://www.nhmrc. gov.au/grants/research-funding-statisticsand-data/funding-datasets (accessed Aug 2013).
4 Parliament of Australia, Community Affairs References Committee. Prevalence of different types of speech, language and communication disorders and speech pathology services in Australia. 2013. http:// www.aph.gov.au/Parliamentary_Business/ Committees/Senate/Community_Affairs/ Speech_Pathology (accessed Feb 2014).
5 Mitchell RJ, McClure RJ, Olivier J, Watson WL.
Rational allocation of Australia's research
dollars: does the distribution of NHMRC
funding by National Health Priority Area
reflect actual disease burden? Med J Aust
2009; 191: 648-652.

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MJA 200 (7) · 21 April 2014

CC Blyth, L Pereira, N Goire

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