Patterns of service utilisation within Australian hepatology clinics: High prevalence of advanced liver disease

Accepted Article Abstract Background: Liver diseases in Australia are estimated to affect 6 million people with a societal cost of $51 billion annually. Information about utilization of specialist hepatology care is critical in informing policy makers about the requirements for delivery of hepatology-related health care. Aims: This study examined etiology and severity of liver disease seen in a tertiary hospital hepatology clinic, as well as resource utilisation patterns. Methods: A longitudinal cohort study included consecutive patients booked in hepatology outpatient clinics during a 3 month period. Subsequent outpatient appointments for these patients over the following 12 months were then recorded. Results: During the initial 3 month period 1471 appointments were scheduled with a hepatologist, 1136 of which were attended. 21% of patients were “new cases”. Hepatitis B (HBV) was the most common disease etiology for new cases (37%). Advanced disease at presentation varied between etiology, with HBV (5%), Hepatitis C (HCV) (31%), non-alcoholic fatty liver disease (NAFLD) (46%) and alcoholic liver disease (ALD) (72%). Most patients (83%) attended multiple hepatology appointments, and a range of referrals patterns for procedures, investigations and other specialty assessments were observed. Conclusions: There is a high prevalence of HBV in new case referrals. Patients with HCV, NAFLD and ALD have a high prevalence of advanced liver disease at referral, requiring ongoing surveillance for development of decompensated liver disease and liver cancer. These findings that describe patterns of health service utilisation among patients with liver disease provide useful information for planning sustainable health service provision for this clinical population

High prevalence of HIV-1 and hepatitis C virus coinfection among injection drug users in the southeastern region of Yunnan, China

The southeastern region of Yunnan province is a key site for drug trafficking and HIV-1 infection spread from the west of Yunnan and Laos to southeastern China. To investigate the prevalence of HIV-1 infection and hepatitis C virus (HCV) coinfection among injection drug users (IDUs) in southeastern Yunnan, three cohorts of 285 addicts, including 242 IDUs and 43 oral drug users, living in the cities of Gejiu and Kaiyuan and the county of Yanshan were studied. HIV-1 and HCV infections were detected by enzyme-linked immunosorbent assay and/or polymerase chain reaction. Data on the age, sex, risk behavior, drug use history, employment, ethnic background, and marriage status were obtained by interview. The overall prevalence of HIV-1 infection was 71.9%. The rate of HCV coinfection among 138 HIV-1-infected IDUs was 99.3%. Most HIV-infected IDUs were 20 to 35 years old (86.7%) and were ethnic Han (75.9%), suggesting that the epidemic in Yunnan is no longer confined to non-Han ethnic minorities, HIV prevalence in female IDUs (81.2%) was significantly higher than in male IDUs (68.2%) (p <.05). The prevalence of HIV infection reached 68.4% after 1 year of injection drug use. Needle/syringe sharing is the major high risk factor for the spread of HIV-1 and HCV infections. Large-scale educational campaigns are urgently needed to reduce the spread of HIV and HCV infection in these regions.

High prevalence of hypovitaminosis D in a Swiss rheumatology outpatient population.

Vitamin D is important for bone metabolism and neuromuscular function. While a routine dosage is often proposed in osteoporotic patients, it is not so evident in rheumatology outpatients where it has been shown that the prevalence of hypovitaminosis D is high. The aim of the current study was to systematically evaluate the vitamin D status in our outpatient rheumatology population to define the severity of the problem according to rheumatologic diseases. During November 2009, all patients were offered a screening test for 25-OH vitamin D levels and categorised as deficient (<10 µg/l [ng/ml] [25 nmol/l]), insufficient (10 µg/l to 30 µg/l [25 to 75 nmol/l]) or normal (>30 µg/l [75 nmol/l]). A total of 272 patients were included. The mean 25-OH vitamin D level was 21 µg/l (range 1.5 to 45.9). A total of 20 patients had vitamin D deficiency, 215 patients had an insufficiency and 37 patients had normal results. In the group of patients with osteoporosis mean level of 25-OH vitamin D was 25 µg/l and 31% had normal results. In patients with inflammatory rheumatic diseases (N = 219), the mean level of 25-OH vitamin D was 20.5 µg/l, and only 12% had normal 25-OH vitamin D levels. In the small group of patients with degenerative disease (N = 33), the mean level of 25-OH vitamin D was 21.8 µg/l, and 21% had normal results. Insufficiency and deficiency were even seen in 38% of the patients who were taking supplements. These results confirm that hypovitaminosis D is highly prevalent in an outpatient population of rheumatology patients, affecting 86% of subjects. Despite oral supplementation (taken in 38% of our population), only a quarter of those on oral supplementation attained normal values of 25-OH vitamin D.

Potential Exposure Risk Associated with the High Prevalence and Survival of Indicator and Pathogenic Bacteria in the Sediment of Vembanadu Lake, India

Prevalence of faecal coliform bacteria and the survival of Escherichia coli, Vibrio parahaemolyticus and Salmonella paratyphi were studied in the water and sediment from Vembanadu Lake in the presence and absence of protozoan predators. The density of faecal coliform bacteria ranged between mean MPN value 5080–9000/100 ml in water and 110,000–988,000/1 g in sediment (p <0.01), which was 110 times greater than in overlying water. The laboratory microcosm studies revealed that E. coli, V. parahaemolyticus and S. paratyphi showed significantly higher survival (p <0.05) potential in sediment than in overlying water both in the presence and absence of protozoan predators. The results indicate that Vembanadu Lake sediment constitutes a reservoir of pathogenic bacteria and exhibits potential health hazard from possible resuspension and subsequent ingestion during recreational activities. Therefore, assessment of bacterial concentration in freshwater lake sediments used for contact and non-contact recreation is of considerable significance for the proper assessment of microbial pollution of the overlying water and the management and protection of related health risk at specific recreational sites. In addition, assessment of the bacterial concentration in sediments can be used as a relatively stable indicator of long-term mean bacterial concentration in the water column above.

High prevalence of multidrug-tolerant bacteria and associated antimicrobial resistance genes isolated from ornamental fish and their carriage water

Background: Antimicrobials are used to directly control bacterial infections in pet (ornamental) fish and are routinely added to the water these fish are shipped in to suppress the growth of potential pathogens during transport. Methodology/Principal Findings: To assess the potential effects of this sustained selection pressure, 127 Aeromonas spp. isolated from warm and cold water ornamental fish species were screened for tolerance to 34 antimicrobials. Representative isolates were also examined for the presence of 54 resistance genes by a combination of miniaturized microarray and conventional PCR. Forty-seven of 94 Aeromonas spp. isolates recovered from tropical ornamental fish and their carriage water were tolerant to >= 15 antibiotics, representing seven or more different classes of antimicrobial. The quinolone and fluoroquinolone resistance gene, qnrS2, was detected at high frequency (37% tested recent isolates were positive by PCR). Class 1 integrons, IncA/C broad host range plasmids and a range of other antibiotic resistance genes, including floR, blaTEM21, tet(A), tet(D), tet(E), qacE2, sul1, and a number of different dihydrofolate reductase and aminoglycoside transferase coding genes were also detected in carriage water samples and bacterial isolates. Conclusions: These data suggest that ornamental fish and their carriage water act as a reservoir for both multi-resistant bacteria and resistance genes.

A high prevalence of antimicrobial resistant Escherichia coli isolated from pigs and a low prevalence of antimicrobial resistant E-coli from cattle and sheep in Great Britain at slaughter

The incidence of antimicrobial resistance and expressed and unexpressed resistance genes among commensal Escherichia coli isolated from healthy farm animals at slaughter in Great Britain was investigated. The prevalence of antimicrobial resistance among the isolates varied according to the animal species; of 836 isolates from cattle tested only 5.7% were resistant to one or more antimicrobials, while only 3.0% of 836 isolates from sheep were resistant to one or more agents. However, 92.1% of 2480 isolates from pigs were resistant to at least one antimicrobial. Among isolates from pigs, resistance to some antimicrobials such as tetracycline (78.7%), sulphonamide (66.9%) and streptomycin (37.5%) was found to be common, but relatively rare to other agents such as amikacin (0.1%), ceftazidime ( 0.1%) and coamoxiclav (0.2%). The isolates had a diverse range of resistance gene profiles, with tet(B), sul2 and strAB identified most frequently. Seven out of 615 isolates investigated carried unexpressed resistance genes. One trimethoprim-susceptible isolate carried a complete dfrA17 gene but lacked a promoter for it. However, in the remaining six streptomycin-susceptible isolates, one of which carried strAB while the others carried aadA, no mutations or deletions in gene or promoter sequences were identified to account for susceptibility. The data indicate that antimicrobial resistance in E. coli of animal origin is due to a broad range of acquired genes.

High prevalence of undernutrition and low dietary diversity in institutionalised elderly living in Sri Lanka

This research received no specific grant from any funding agency in the public, commercial and not-for-profit sectors. The authors wish to thank the participants, administrators and caregivers of the homes for elders for their enthusiastic cooperation and also the Nutrition Research Team of the Department of Applied Nutrition, Wayamba University of Sri Lanka, for their valuable assistance during the course of the study. The authors also wish to thank Mr. S. Rahanan for coordination and the assistance given in data collection especially in Tamil speaking participants. K.M.R designed and managed the study, interpreted the data and drafted the manuscript. M.P.P.M contributed to the data collection, data analysis and coordination of the study. M.W, K.G.J and J.A.L assisted in data interpretation and critical revision of the manuscript. The authors declare that there is no conflict of interest of any kind involved in this study or this publication. Ethical clearance for this study was obtained from the Ethical Review Committee of the Sri Lanka Medical Association (ERC/13-037).

Enablers and barriers to accessing mental health services for adults with high prevalence psychological disorders in South West Victoria

Knowing what services are available and how to access them can be challenging in rural areas. The aim of the South West Mental Health Mapping project was to identify the level, accessibility and effectiveness of mental health services for high prevalence psychological disorders amongst the adult population in the South West region of Victoria. This study includes data from a number of sources: regional records of the number and location of health professionals; a telephone survey of 1297 people in five Local Government Areas in the region; and a social network analysis of contact points. Additional qualitative interviews and surveys were conducted with 25 service recipients and 37 health professionals to identify issues from different perspective. This paper will focus on the social network analysis of the project. It highlights the relative prominence of each type of service provider within the overall network. The social network map shows the centrality of the General Practitioner and the wide range of agencies that become involved in supporting people with mental health issues. The discussion identifies primary contact points for people seeking help and places of referral. The main barrier acknowledged by people requiring assistance was lack of knowledge about where to go for help. Enablers included Medicare Better Access funded schemes. The findings show that there is a reasonable range of mental health professionals across the region, although there are challenges with recruitment and retention of staff. Even with available services, a major problem is communicating this information to potential consumers

High prevalence of symptoms associated with ovarian cancer among Australian women

Background: Symptoms associated with ovarian cancer are often vague and non-specific, such as abdominal bloating and pain. Presently, nothing is known about the prevalence of these symptoms among women in the community.
Aims: To identify the prevalence and correlates of symptoms associated with ovarian cancer in a nationally representative sample of Australian women.
Methods: Women answered questions about symptoms associated with ovarian cancer via computer-assisted telephone interviews. Binomial regression was used to assess the association between reporting symptoms, demographic characteristics and sexual problems.
Results: Data on 2235 women aged 18–70 who had not had an oophorectomy or hysterectomy were analysed.
Prevalences of symptoms were abdominal bloating 52%, abdominal pain 37%, increased abdominal size 30%, pelvic pain 29%, feeling full quickly 18% and unable to eat normally 15%. One-third of women (32%) reported three or more symptoms, 2% reported all six and 32% of women reported none. Severe symptoms were generally reported by <10% of women reporting symptoms, and symptoms usually persisted for 5 days or less a month. Older women were less likely to report symptoms, as were women who had been pregnant. There was an association between symptoms and sexual difficulties whereby women who reported multiple ovarian cancer symptoms were more likely to report sexual problems.
Conclusions: There is a high prevalence of ovarian cancer symptoms in the Australian community. Because of this, awareness campaigns will likely impact a large number of women who do not have ovarian cancer.

The high prevalence of vitamin D insufficiency across Australian populations is only partly explained by season and latitude

Background Inadequate sun exposure and dietary vitamin D intake can result in vitamin D insufficiency. However, limited data are available on actual vitamin D status and predictors in healthy individuals in different regions and by season.

Methods We compared vitamin D status [25-hydroxyvitamin D; 25(OH)D] in people < 60 years of age using data from cross-sectional studies of three regions across Australia: southeast Queensland (27°S; 167 females and 211 males), Geelong region (38°S; 561 females), and Tasmania (43°S; 432 females and 298 males).

Results The prevalence of vitamin D insufficiency (≤ 50 nmol/L) in women in winter/spring was 40.5% in southeast Queensland, 37.4% in the Geelong region, and 67.3% in Tasmania. Season, simulated maximum daily duration of vitamin D synthesis, and vitamin D effective daily dose each explained around 14% of the variation in 25(OH)D. Although latitude explained only 3.9% of the variation, a decrease in average 25(OH)D of 1.0 (95% confidence interval, 0.7–1.3) nmol/L for every degree increase in latitude may be clinically relevant. In some months, we found a high insufficiency or even deficiency when sun exposure protection would be recommended on the basis of the simulated ultraviolet index.

Conclusion Vitamin D insufficiency is common over a wide latitude range in Australia. Season appears to be more important than latitude, but both accounted for less than one-fifth of the variation in serum 25(OH)D levels, highlighting the importance of behavioral factors. Current sun exposure guidelines do not seem to fully prevent vitamin D insufficiency, and consideration should be given to their modification or to pursuing other means to achieve vitamin D adequacy.

Prospective progression from high-prevalence disorders to bipolar disorder: exploring characteristics of pre-illness stages

BACKGROUND: Identification of risk factors within precursor syndromes, such as depression, anxiety or substance use disorders (SUD), might help to pinpoint high-risk stages where preventive interventions for Bipolar Disorder (BD) could be evaluated.

METHODS: We examined baseline demographic, clinical, quality of life, and temperament measures along with risk clusters among 52 young people seeking help for depression, anxiety or SUDs without psychosis or BD. The risk clusters included Bipolar At-Risk (BAR) and the Bipolarity Index as measures of bipolarity and the Ultra-High Risk assessment for psychosis. The participants were followed up for 12 months to identify conversion to BD. Those who converted and did not convert to BD were compared using Chi-Square and Mann Whitney U tests.

RESULTS: The sample was predominantly female (85%) and a majority had prior treatment (64%). Four participants converted to BD over the 1-year follow up period. Having an alcohol use disorder at baseline (75% vs 8%, χ(2)=14.1, p<0.001) or a family history of SUD (67% vs 12.5%, χ(2)=6.0, p=0.01) were associated with development of BD. The sub-threshold mania subgroup of BAR criteria was also associated with 12-month BD outcomes. The severity of depressive symptoms and cannabis use had high effects sizes of association with BD outcomes, without statistical significance.

CONCLUSIONS AND LIMITATIONS: The small number of conversions limited the power of the study to identify associations with risk factors that have previously been reported to predict BD. However, subthreshold affective symptoms and SUDs might predict the onset of BD among help-seeking young people with high-prevalence disorders.