Clinical features and risk factors of oedematous Mycobacterium ulcerans lesions in an Australian population: beware cellulitis in an endemic area

Introduction
Oedematous lesions are a less common but more severe form of Mycobacterium ulcerans disease. Misdiagnosis as bacterial cellulitis can lead to delays in treatment. We report the first comprehensive descriptions of the clinical features and risk factors of patients with oedematous disease from the Bellarine Peninsula of south-eastern Victoria, Australia.

Methods
Data on all confirmed Mycobacterium ulcerans cases managed at Barwon Health, Victoria, were collected from 1/1/1998–31/12/2012. A multivariate logistic regression model was used to assess associations with oedematous forms of Mycobacterium ulcerans disease.

Results
Seventeen of 238 (7%) patients had oedematous Mycobacterium ulcerans lesions. Their median age was 70 years (IQR 17–82 years) and 71% were male. Twenty-one percent of lesions were WHO category one, 35% category two and 41% category three. 16 (94%) patients were initially diagnosed with cellulitis and received a median 14 days (IQR 9–17 days) of antibiotics and 65% required hospitalization prior to Mycobacterium ulcerans diagnosis. Fever was present in 50% and pain in 87% of patients. The WCC, neutrophil count and CRP were elevated in 54%, 62% and 75% of cases respectively. The median duration of antibiotic treatment was 84 days (IQR 67–96) and 94% of cases required surgical intervention. On multivariable analysis, there was an increased likelihood of a lesion being oedematous if on the hand (OR 85.62, 95% CI 13.69–535.70; P<0.001), elbow (OR 7.83, 95% CI 1.39–43.96; p<0.001) or ankle (OR 7.92, 95% CI 1.28–49.16; p<0.001), or if the patient had diabetes mellitus (OR 9.42, 95% CI 1.62–54.74; p = 0.02).

Conclusions
In an Australian population, oedematous Mycobacterium ulcerans lesions present with similar symptoms, signs and investigation results to, and are commonly mistakenly diagnosed for, bacterial limb cellulitis. There is an increased likelihood of oedematous lesions affecting the hand, elbow or ankle, and in patients with diabetes.

Multiple origins of the endemic Australian Macrobrachium (Descapoda: Palaemonidae) based on 16S rRNA mitochondrial sequences

The evolutionary relationships of the freshwater prawn genus Macrobrachium are obscure. Members of this genus are widely distributed across tropical and subtropical regions. The phylogenetic relationships among the seven endemic and six non-endemic Australian Macrobrachium, along with five non-Australian species, were inferred from the mitochondrial 16S rRNA gene sequences. Methods of analysis yielded phylogenetic trees of differing topologies; however, none supported a monophyletic origin for endemic Australian Macrobrachium. Enforced monophyly of a single origin of endemic Macrobrachium was statistically tested and rejected. These results support the view that the endemic Australian Macrobrachium arose from multiple origins. Previous biogeographical hypotheses related to the radiation of Macrobrachium into Australia are re-examined in the context of these results.

Mycobacterium ulcerans infection : factors influencing diagnostic delay

Objective: To document the epidemiology, clinical characteristics and diagnosis of an outbreak of Mycobacterium ulcerans infection (Bairnsdale or Buruli ulcer [BU]) during the period 1998–2006, and compare delays in diagnosis between residents of endemic and non-endemic regions.

Design and setting: Retrospective case study of patients identified through infectious disease physicians on the Bellarine Peninsula and the Victorian Department of Human Services notifiable diseases database.

Main outcome measures: Description of events leading to diagnosis of BU.

Results: Eighty-five BU patients recalled their experience. Fifty-three patients were older than 60 years, and 61 permanently resided on the Bellarine Peninsula. The onset of symptoms occurred most frequently in mid winter. Twenty-eight patients had lesions on the arm and 51 on the leg. The median time between onset of symptoms and first medical contact was shorter for those living in the endemic area (3.0 weeks; interquartile range [IQR], 1.0–5.0 weeks) compared with non-endemic areas (5.3 weeks; IQR, 2.0–9.5 weeks) (P = 0.05). Patients who resided in the endemic area had a shorter median time from their first medical appointment to diagnosis (1.0 week; IQR, 0.0–3.9 weeks) than those who resided in non-endemic areas (5.0 weeks; IQR, 1.3–8.0 weeks) (P = 0.001).

Conclusion: Delay in presentation and time to diagnosis of BU are longer in non-endemic than endemic areas. Measures should be taken to raise awareness of the disease in non-endemic areas.

Somewhat saved : a captive breeding programme for two endemic Christmas Island lizard species, now extinct in the wild

As with many islands, Christmas Island in the Indian Ocean has suffered severe biodiversity loss. Its terrestrial lizard fauna comprised five native species, of which four were endemic. These were abundant until at least the late 1970s, but four species declined rapidly thereafter and were last reported in the wild between 2009 and 2013. In response to the decline, a captive breeding programme was established in August 2009. This attempt came too late for the Christmas Island forest skink Emoia nativitatis, whose last known individual died in captivity in 2014, and for the non-endemic coastal skink Emoia atrocostata. However, two captive populations are now established for Lister's gecko Lepidodactylus listeri and the blue-tailed skink Cryptoblepharus egeriae. The conservation future for these two species is challenging: reintroduction will not be possible until the main threats are identified and controlled.

Lay healing practices in the household

This thesis explores the power-knowledge relationship underlying lay healing practices in the household; a non-traditional area of study in public health. Lay knowledge continues to be discounted as illegitimate and !non-expert' by policymakers, health professionals and academics. Given the absence of theory on lay knowledge and decision-making, an eclectic theoretical approach was undertaken in this study. Theory is drawn from medical anthropology, sociology of the body, health economics, gender studies, social theory, psychology, nursing, ethics, philosophy and history of medicine in order to contribute to and advance debate. Operating within the genre of a 'multi-sited ethnography' (working across different sites), methods for data collection included 'anthropology at home' by undertaking fieldwork in Geelong, Victoria, Australia. I conducted interviews and focus group discussions with, and administered a questionnaire to, 98 participants who are parents of young children. They were recruited via primary schools and snowball sampling. The quantitative data presents a socio-demographic 'picture' of 78 women and 20 men (representing 98 households) from urban, rural and coastal areas of the region. The qualitative data contains case studies as well as narratives, analysed for their content and discourses. Additional methods included maintenance of a 'reflexive journal', inter-sectoral consultations and public health policy analysis. Research findings indicate laypeople's conceptualisations of the body, self, health and illness rest upon a notion of the embodied self and health that is physical, mental and spiritual. Lay people have a substantial knowledge base on health and ill-health that derives from many sources, is both generalised and specialised, and is set within the context of everyday life. Laypeople make diagnoses and treat illness and injury within the household. They also exercise substantial agency in determining their choice of healer(s) for therapeutic intervention and management of ill-health outside the household. This study has substantial implications for public health in terms of healers' clinical practices, research and policy.

Cost-effectiveness analysis of a two-stage screening intervention for hepatocellular carcinoma in Taiwan

Background/Purpose

Hepatocellular carcinoma (HCC) has been the leading cause of cancer death in Taiwan since the 1980s. A two-stage screening intervention was introduced in 1996 and has been implemented in a limited number of hospitals. The present study assessed the costs and health outcomes associated with the introduction of screening intervention, from the perspective of the Taiwanese government. The cost-effectiveness analysis aimed to assist informed decision making by the health authority in Taiwan.
Methods

A two-phase economic model, 1-year decision analysis and a 60-year Markov simulation, was developed to conceptualize the screening intervention within current practice, and was compared with opportunistic screening alone. Incremental analyses were conducted to compare the incremental costs and outcomes associated with the introduction of the intervention. Sensitivity analyses were performed to investigate the uncertainties that surrounded the model.
Results

The Markov model simulation demonstrated an incremental cost-effectiveness ratio (ICER) of NT$498,000 (US$15,600) per life-year saved, with a 5% discount rate. An ICER of NT$402,000 (US$12,600) per quality-adjusted life-year was achieved by applying utility weights. Sensitivity analysis showed that excess mortality reduction of HCC by screening and HCC incidence rates were the most influential factors on the ICERs. Scenario analysis also indicated that expansion of the HCC screening intervention by focusing on regular monitoring of the high-risk individuals could achieve a more favorable result.
Conclusion

Screening the population of high-risk individuals for HCC with the two-stage screening intervention in Taiwan is considered potentially cost-effective compared with opportunistic screening in the target population of an HCC endemic area.

Risk factors for Mycobacterium ulcerans infection, southeastern Australia

Buruli/Bairnsdale ulcer (BU) is a severe skin and soft tissue disease caused by Mycobacterium ulcerans. To better understand how BU is acquired, we conducted a case-control study during a sustained outbreak in temperate southeastern Australia. We recruited 49 adult patients with BU and 609 control participants from a newly recognized BU-endemic area in southeastern Australia. Participants were asked about their lifestyle and insect exposure. Odds ratios were calculated by using logistic regression and were adjusted for age and location of residence. Odds of having BU were at least halved for those who frequently used insect repellent, wore long trousers outdoors, and immediately washed minor skin wounds; odds were at least doubled for those who received mosquito bites on the lower legs or lower arms. This study provides new circumstantial evidence that implicates mosquitoes in the transmission of M. ulcerans in southeastern Australia.

Hope for resurrecting a functionally extinct parrot or squandered social capital? Landholder attitudes towards the Orange-bellied Parrot (Neophema chrysogaster) in Victoria, Australia

In early 2010, after 27 years of recovery effort, the orange-bellied parrot (OBP; Neophema chrysogaster) was expected to be extinct in the wild within a few years. Shortly before the imminent wild extinction became evident, we surveyed landholders (114 responses of 783 surveys delivered) in part of the main non-breeding area, according to three classes of modelled habitat suitability ('high', 'medium', and 'low'). Predictions of the habitat models appear to correlate with landholder perceptions of the presence of OBP habitat on private land, thus the models appear a tractable way to identify key stakeholders worthy of priority consultation in relation to habitat works. Landholders were sympathetic to wetlands and birds, including OBPs (89.4% were aware of OBPs). Most indicated that they would be upset if the OBP went extinct and agreed that critical habitat should be protected; 80.7% were prepared to consider changes to the way they managed their land to benefit the species, and sought more information on how they could do so (64.0%). This study suggests that the habitat model usefully identified key stakeholders and the OBP enjoyed high awareness, concern, and engagement among many stakeholders, shortly before the species was considered functionally extinct. The maintenance of landholder support is likely to be critical if future attempts are made to reintroduce the species to the wild.

SAS macros for point and interval estimation of area under the receiver operating characteristic curve for non-proportional and proportional hazards Weibull models

Aims and objectives  For prediction of risk of cardiovascular end points using survival models the proportional hazards assumption is often not met. Thus, non-proportional hazards models are more appropriate for developing risk prediction equations in such situations. However, computer program for evaluating the prediction performance of such models has been rarely addressed. We therefore developed SAS macro programs for evaluating the discriminative ability of a non-proportional hazards Weibull model developed by Anderson (1991) and that of a proportional hazards Weibull model using the area under receiver operating characteristic (ROC) curve.

Method  Two SAS macro programs for non-proportional hazards Weibull model using Proc NLIN and Proc NLP respectively and model validation using area under ROC curve (with its confidence limits) were written with SAS IML language. A similar SAS macro for proportional hazards Weibull model was also written.

Results  The computer program was applied to data on coronary heart disease incidence for a Framingham population cohort. The five risk factors considered were current smoking, age, blood pressure, cholesterol and obesity. The predictive ability of the non-proportional hazard Weibull model was slightly higher than that of its proportional hazard counterpart. An advantage of SAS Proc NLP in terms of the example provided here is that it provides significance level for the parameter estimates whereas Proc NLIN does not.

Conclusion  The program is very useful for evaluating the predictive performance of non-proportional and proportional hazards Weibull models.

Linking environmental uncertainty to non-financial performance measures and performance : a research note

Several previous research studies have reported mixed results concerning the direct association between non-financial performance measures and  performance. The presence of environmental uncertainty on this relationship has not been established. This paper makes a contribution to this area by proposing that it is in conditions of environmental uncertainty that non-financial measures are most useful in improving organizational performance. It analyses empirical data from a sample of New Zealand manufacturing organizations to test the hypothesis that non-financial measures of performance would lead to improved organizational performance under conditions of increased environmental uncertainty. Multiple regression analysis of the data suggests that performance should be a declining function of the size of the ‘mismatch’ between an organization's environment and use of the different combinations of non-financial performance measures. Further, the paper concludes that prior mixed results may be attributed to the omission of environmental uncertainty.

Culture-based fisheries in non-perennial reservoirs in Sri Lanka: production and relative performance of stocked species

In Sri Lanka, there is a great potential for the development of culture-based fisheries because of the availability of around 12 000 non-perennial reservoirs in the dry zone (<187 cm annual rainfall) of the island. These reservoirs fill during the north-east monsoonal period in October to December and almost completely dry up during August to October. As these non-perennial reservoirs are highly productive, hatchery-reared fish fingerlings can be stocked to develop culture-based fisheries during the water retention period of 7–9 months. The present study was conducted in 32 non-perennial reservoirs in five administrative districts in Sri Lanka. These reservoirs were stocked with fingerlings of Indian (catla Catla catla Hamilton and rohu Labeo rohita Hamilton) and Chinese (bighead carp Aristichthys nobilis Richardson) major carps, common carp Cyprinus carpio L., genetically improved farmed tilapia (GIFT) strain of Nile tilapia, Oreochromis niloticus (L.) and post-larvae of giant freshwater prawn, Macrobrachium rosenbergii De Man, at three different species combinations and overall stocking densities (SD) ranging from 218 to 3902 fingerlings ha⁻¹, during the 2002–2003 culture cycle. Of the 32 reservoirs stocked, reliable data on harvest were obtained from 25 reservoirs. Fish yield ranged from 53 to 1801 kg ha⁻¹ and the yields of non-perennial reservoirs in southern region were significantly (P < 0.05) higher than those in the northern region. Naturally-recruited snakehead species contributed the catches in northern reservoirs. Fish yield was curvilinearly related to reservoir area (P < 0.05), and a negative second order relationship was evident between SD and yield (P < 0.05). Chlorophyll-a and fish yield exhibited a positive second order relationship (P < 0.01). Bighead carp yield impacted positively on the total yield (P < 0.05), whereas snakehead yield impact was negative. Bighead carp, common carp and rohu appear suitable for poly-culture in non-perennial reservoirs. GIFT strain O. niloticus had the lowest specific growth rate among stocked species and freshwater prawn had a low return.

Culture-based fisheries in non-perennial reservoirs of Sri Lanka: influence of reservoir morphometry and stocking density on yield

Culture-based fish yield in non-perennial reservoirs of Sri Lanka was related to reservoir morphometry and stocking density. The reservoirs were stocked mainly with fingerlings of one Chinese and three Indian major carp species, common carp, Cyprinus carpio L., and the genetically improved farmed tilapia strain of Nile tilapia, Oreochromis niloticus (L.), at four pre-determined species combinations and a range of stocking densities [SD (fingerlings ha⁻¹)]. Twenty-three reservoirs were harvested successfully at the end of the culture period of 2002–2003. Basic limnological and morphometric parameters, including shoreline development (D_L) and shoreline area ratio (R_LA), were estimated for each of the 23 reservoirs. Bray–Curtis similarity and non-metric multidimensional scaling using mean values of limnological data revealed that reservoirs could be ordinated into two major clusters, one with intact sample distribution due to similar trophic characteristics and the other with scattered sample distribution. Reservoirs in the cluster with similar trophic characteristics showed significant correlation (P < 0.05) between R_LA and total fish yield (Y). A multiple regression equation, Y = −693 + 4810 R_LA + 0.484 SD, was generated to estimate fish harvest in relation to SD.

Non-invasive sampling techniques : applications for mapping the generic variation of powerful owls

The Powerful Owl (Ninox strenua) is endemic to Australia, being resident in the three eastern mainland states and the Australian Capital Territory. It is classified nationally as of conservation significance and vulnerable in the state of Victoria. The elusive nature of this owl, along with its dispersed distribution, low population density and difficulty in identifying individual birds, limit the collection of ecological data. Molecular methods can be used to obtain crucial ecological information, essential for Powerful Owl conservation.

Non-invasive sampling is a relatively new method used for obtaining genetic material from free-ranging animals. This type of sampling however, is generally overlooked as a potential DNA source. Shed hair and feathers, faeces, urine, skins and eggshells are all potential sources of DNA. Non-invasive sampling regimes may be the only alternative for the genetic analysis of endangered and/or elusive species that are difficult to sample otherwise.

Powerful Owls moult annually. Shed feathers therefore, can be collected from under roost trees and used for genetic analysis. Feathers collected provide DNA that is unique to the individual and can provide additional ecological knowledge of the species.

In this study we collected shed Powerful Owl feathers during 2003 and 2004. In order to obtain samples from across the owl's large distribution, public awareness about the project via the way of flyers, mail-outs, media sources (radio, newspapers and magazines), email lists and public seminars was initiated. Overall, the collection strategy was very successful with over 500 Powerful Owl feather samples being collected.

Genetic information obtained from the analysis of DNA from feathers can enable a more rigorous assessment of population viability of the Powerful Owl. Specifically designed molecular markers will facilitate unequivocal identification of individual birds ("DNA fingerprinting"). Through the application of molecular techniques we can collect ecological information about the Powerful Owl such as, genetic divergence, population structure, dispersal patterns, migration and inbreeding. These questions can not be addressed via traditional data collection and will contribute significantly to the successful conservation of the Powerful Owl and potentially other raptor species.

Sexing accuracy and indicators of maturation status in captive Murray cod Maccullochella peelii peelii using non-invasive ultrasonic imagery

Macroscopic- and histological-based assessments of gonad condition were compared with ultrasound images to determine the feasibility of this technology as a non-invasive diagnostic tool for identifying sex and assessing maturation status of Murray cod. Four age-classes (1⁺, 2⁺, 3⁺ and 6⁺ years), were sub-sampled at monthly intervals throughout their annual reproductive cycle and scanned with a 5 MHz linear transducer. An interpretation of sex was made from the resulting images and maximum cross-sectional gonad diameter and area were recorded. Fish were subsequently dissected to confirm gender, and the weights and maturation status of gonads determined and then compared with their respective image profile. Ovaries of females were usually a distinctive feature in ultrasound images, being particularly obvious in older and/or more developed fish. In contrast, the identification of male testis was more problematic. Nonetheless, identifying sex from ultrasound images was consistently achieved by recording the presence/absence of a female ovary (96% total sexing accuracy). Maximum cross-sectional ovary diameter and area were highly correlated with gonad weight (r² = 0.90 and 0.89, respectively) suggesting that indices of maturation status, comparable to the gonadosomatic index (GSI), can be obtained non-destructively from ultrasound scans of females. A less distinct relationship occurred between these dimensions and weight of testes (r² = 0.41). Significant increases (P < 0.05) in mean gonad index (GI, calculated from gonad diameter) occurred for most gonad development stages. However, differences in mean GI between maturation stages were confounded by phenotypic variability, indicating that GI may be limited to population level studies. Nevertheless, ultrasound images of ovaries at each development stage were visually distinctive and enabled qualitative evaluations of maturity, thereby complementing quantitative GI assessments. Repeated serial-monitoring of the same population using ultrasound appears to have great potential for tracking maturation-induced changes in broodfish.