Royal Darwin Hospital Research Articles

Retrospective review of febrile neutropenia in the Royal Darwin Hospital, 1994-99.

Febrile neutropenia is a life-threatening complication of cytotoxic chemotherapy. Empirical antibiotic treatment should be based on predominant pathogens and epidemiological characteristics of the treated community. The aim of the present study was to review cases of febrile neutropenia at the Royal Darwin Hospital (RDH) in order to assess the appropriateness of empirical antibiotic therapy. A retrospective review of cases of febrile neutropenia secondary to malignancy or chemotherapy occurring at the RDH over the period 1994-99. In order to compare infections in this group with those in the wider hospital community, all positive blood cultures in the medical and intensive care units were reviewed for the same time period. Thirty-six episodes of febrile neutropenia were reviewed. Staphylococcus aureus (predominantly methicillin resistant), Pseudomonas aeruginosa and Escherichia coli were the most common organisms identified. Nine patients died of their infection, four with methicillin-resistant S. aureus bacteraemia. S. aureus, E. coli, Streptococcus pneumoniae and Burkholderia pseudomallei (melioid) were the most frequently isolated organisms from blood cultures taken in the medical and intensive care units. Gram-positive organisms are the predominant pathogens in febrile neutropenic episodes at the RDH. Standard empirical therapy with an extended-spectrum penicillin and an aminoglycoside remains appropriate, with the addition of vancomycin when clinical status fails to improve. When practising in the Top End, particular consideration should be given to skin integrity and scabies and testing for Strongyloides in Aboriginal patients.

Paediatric melioidosis in the Northern Territory of Australia: an expanding clinical spectrum.

The objective of this study was to present the laboratory and clinical features of the six cases of paediatric melioidosis diagnosed from 1997-2000. All cases of melioidosis confirmed by the pathology department of Royal Darwin Hospital were prospectively identified by culture and/or serology. Four children were Aboriginal and all six cases presented during the rainy season (November-April) in rural areas in the tropical Top End of the Northern Territory. Delay in diagnosis ranged from 5 and 11 days. Two cases had localized melioidosis, two cases had underlying disease and were likely to be colonized with Burkholderia pseudomallei (B. pseudomallei). Two cases had neurological melioidosis with major residual disability. No deaths occurred. Melioidosis remains an unusual disease in children in the tropical Northern Territory. The average annual incidence since 1997 is 5.48 per 100 000. This series demonstrates that children in Australia can have serious neurological complications from B. pseudomallei infection. All children living in or visiting tropical Australia are at risk, especially those residing in rural areas in the rainy season. Melioidosis remains a difficult disease to manage, and expert opinion should be sought if B. pseudomallei is cultured from any site.

Antibiotic susceptibility of Burkholderia pseudomallei from tropical northern Australia and implications for therapy of melioidosis

From a prospective melioidosis study commencing in 1989 at Royal Darwin Hospital, 170 initial isolates of Burkholderia pseudomallei were available for susceptibility testing. Of these 163 (96%) were susceptible to meropenem/imipenem, ceftazidime, trimethoprim-sulphamethoxazole (SMX/TMP) and doxycycline. Seven (4%) showed primary resistance; three had low-level resistance to SMX/TMP, one to ceftriaxone and amoxycillin/clavulanate (AMOX/CA) and three to doxycycline. Of 167 patients who survived their initial presentation, seven (4%) had culture positive infections which persisted for greater than 3 months after start of therapy. All ultimately cleared carriage of B. pseudomallei though three required changing to SMX/TMP after development of doxycycline resistance. Nineteen (11%) of the initial survivors clinically relapsed and 17 of these had repeat isolates available for testing. Four of these had acquired resistance: one to doxycycline, one to AMOX/CA and ceftazidime, one to SMX/TMP and one to both SMX/TMP and doxycycline. Molecular typing using randomly amplified polymorphic DNA and pulsed-field gel electrophoresis showed all but one relapse isolate to be the same as the original strain. These data are similar to published data from Thailand. As melioidosis has a high mortality (21% in this series) these results emphasize the need for prolonged eradication therapy and regular clinical and microbiological monitoring so that the emergence of resistance can be detected early and appropriate treatment modifications made.

EFFECT OF MORBIDITIES ON COSTS OF END‐STAGE RENAL DISEASES (ESRD) PATIENTS IN THE TOP END OF THE NT

Objectives The continuing care cost of maintaining ESRD patients includes not only the cost of dialysis, but also the costs of treating comorbidities related to dialysis treatments (MRD) and not related to dialysis treatments. This study examined the relationship between comorbidities and costs. Methods: Cost information of ESRD patients was derived from Royal Darwin Hospital costing study in 1996/97 and 1997/98 financial years. Diagnosis Related Groups (DRGs) assigned to patients who were hospitalised were re‐categorised as 19 groups of comorbidites. Multiple linear regression (MLR) model was developed to analyse the relationship between diseases and costs. A forward selection strategy was applied to select diseases significantly affecting costs. Results: In that 2‐year period, 167 people (102 Aboriginals (A), and 65 non Aboriginals) were treated for ESRD, at a total cost of $12.7million. Provision of dialysis treatment alone cost $9.7m (76% of total cost). One hundred and thirteen people (85% of A, 40% of non A) had intercurrent hospitalisations for comorbidities at a cost of $3m (24%), with 530 episodes. Of these episodes, the most frequent reasons of admission for A were: water and electrolyte disorder (WED 25%), respiratory diseases (RD 20%), and surgical procedure (13%), while for non A, they were cardiovascular diseases (CVD 27%), WED (17%) and SP (15%) (see below). The following diseases (p < 0.05) were chosen in the final MLR model in terms of cost: SP, RD, CVD, WED, MRD, and access procedure etc. SP, RD and CVD accounted for 30%, 18%, and 11% of the $3m. % of episodes SP RD CVD WED MRD Access AB (% of 422) 13 20 12 25 5 0.9 non AB (% of 88) 15 7 27 17 5 5 Cost % 30 18 11 9 6 5 ConclusionsTo reduce the continuing care costs for ESRD patients, greater efforts must be made to decrease the comorbidities. Prevention of surgical diseases, respiratory infection, and heart diseases might reduce the morbidity rate in ESRD patients, and subsequently reduce costs.

Evaluation of a telemedicine link between Darwin and Adelaide to facilitate cancer management.

The videoconferencing link between the Royal Adelaide Hospital Cancer Centre in South Australia and the Royal Darwin Hospital in the Northern Territory was established to allow Darwin clinicians to discuss cases in multidisciplinary oncology meetings at the tertiary referral center. This was evaluated by questionnaires distributed to the 20 health professionals involved and a group of 8 patients with breast cancer whose case histories had been discussed via videoconferencing. All clinicians found the telemedicine link to be either useful or very useful in at least one aspect of their practice. The major benefit was cited as enabling remote area clinicians to participate in multidisciplinary cancer meetings. Three of the 5 remote clinicians who practiced solely in the Northern Territory found that the telemedicine consultation increased their workload, while only 2 of 13 clinicians who practiced solely in South Australia reported an increase over their normal activities, the others reporting no difference. Benefits identified included better support of isolated clinicians, decreased travel, and enhanced education and peer review. Perceived difficulties were technical problems, the impersonal nature of the interaction, inability to examine the remote patient and lack of reimbursement for the consultation. Seven of the eight patients surveyed were satisfied or very satisfied with the telemedicine consultation. Four patients wished to have access to videotape of the multidisciplinary meeting. Of those requiring travel for treatment, all believed that the telemedicine consultation influenced their care and shortened their time away from home.

Neurological melioidosis

Neurological abnormalities have long been recognised in animals with melioidosis, including laboratory rodents and sheep in the first Australian outbreak in 1949. Autopsies in animals have shown microabscesses and lymphocytic infiltration to be present on occasion in the same animal, but Burkholderia pseudomallei is usually able to be grown from central nervous system (CNS) tissue. In humans CNS melioidosis is unusual, but both macroscopic brain abscesses and encephalitis occur. There has been a recently recognised syndrome of meningoencephalitis with varying involvement of brainstem, cerebellum and spinal cord. The prospective melioidosis study at Royal Darwin Hospital has documented 12 cases of CNS melioidosis over 9 years out of a total of 232 cases of melioidosis (5%). Prominent features on presentation were unilateral limb weakness (6), predominant cerebellar signs (2), mixed cerebellar and brainstem features with peripheral weakness (2) and flaccid paraparesis (2). Eight patients had unilateral VIIth nerve palsy and six bulbar palsy, with five requiring prolonged ventilation. Brain CT scans are usually normal initially, but MRI shows dramatic changes. Three patients died and only three made a full recovery. In two patients with predominant mononuclear CSF pleocytosis, B. pseudomallei was cultured from CSF and autopsy in one of these showed necrotising encephalitis with microabscesses. Although it has been postulated that a neurotropic exotoxin may account for melioidosis encephalomyelitis, the recent findings and comparison with the animal data suggest that direct organism spread within the CNS may be primarily responsible. Preliminary molecular typing of isolates shows no evidence of a specific strain of B. pseudomallei responsible for CNS melioidosis and further studies are required to determine if the apparent higher rate of CNS disease in Australia is due to true regional differences or is from increased ascertainment.

The epidemiology of melioidosis in Australia and Papua New Guinea

Melioidosis was first described in Australia in an outbreak in sheep in 1949 in north Queensland (22°S). Human melioidosis was first described from Townsville (19°S) in 1950. Melioidosis is hyperendemic in the Top End of the Northern Territory (NT) and as in parts of northeastern Thailand it is the commonest cause of fatal community-acquired septicemic pneumonia. In the 9 years since 1989 the prospective NT melioidosis study at Royal Darwin Hospital (12°S) has documented 206 culture confirmed cases of melioidosis, with an average annual incidence of 16.5/100 000. Melioidosis is also seen in the north of Western Australia and north Queensland, including the Torres Strait Islands, but is uncommon in adjacent Papua New Guinea. Serological studies suggest that infection is rare in the Port Moresby region, but there is emerging evidence of melioidosis from Western Province. The NT study has documented inoculating events in 52 (25%) of cases, with an incubation period of 1–21 days (mean 9 days); 84% of cases had acute disease from presumed recent acquisition and 13% had chronic disease (sick, >2 months). In 4% there was evidence of possible reactivation from a latent focus; 28 of 153 (18%) males had prostatic abscesses. The overall mortality was 21% (43 cases), with a mortality rate in septicemic cases (95) of 39% and in non-septicemic cases (103) of 4%. Pneumonia was the commonest presentation in both groups and, in addition, eight patients (two deaths) presented with melioidosis encephalomyelitis. Melioidosis clusters in temperate Australia are attributed to animals imported from the north. Molecular typing of Burkholderia pseudomallei isolates from temperate southwest Western Australia showed clonality over 25 years. In this outbreak and in studies from the NT, some soil isolates are molecularly identical to epidemiologically related animal and human isolates. Molecular typing has implicated the water supply in two clonal outbreaks in remote aboriginal communities in northern Australia. Further prospective collaborative studies are required to evaluate whether there are truly regional differences in clinical features of melioidosis and to better understand how B. pseudomallei is acquired from the environment.

A retrospective search for lyssavirus in humans in the Northern Territory

BackgroundFollowing the 1996 discovery of a rabies-like lyssavirus in Australian flying foxes, it was unclear whether this was a new epizootic or an unrecognised, previously existing disease. ObjectiveTo review cases of unexplained encephalitis in the Northern Territory (NT) to test available clinical specimens for lyssavirus and survey the use of diagnostic tests by clinicians. MethodsThe NT hospital morbidity database was searched from January 1992 to September 1996 for all Royal Darwin Hospital (RDH) cases with an ICD-9 code encompassing encephalitis or viral meningitis. Final diagnoses were determined by hospital record review. For cases of unexplained encephalitis, we assessed the use of diagnostic tests and located clinical specimens for testing for lyssavirus-specific inclusion bodies via immunohistochemistry, immuo-flourescence and reverse-transcriptase polymerase chain reaction (RT-PCR). ResultsEncephalitis occurred in 34/154 (22%) cases located by the search; 53% (18/34) of encephalitis cases were unexplained. Of these, 24% had no serology performed and 47% had no blood cultures taken. Four (22%) died and two had autopsies. These were the only two cases with clinical specimens available for testing. They were negative for lyssavirus. None of the 71 cases coded as viral meningitis had unexplained encephalitis. ConclusionThere was a considerable proportion of unexplained illness among NT cases of encephalitis. ImplicationsClinicians should test for lyssavirus in patients with encephalitic symptoms and a postmortem should be sought where death is unexplained. Specimens should be stored to enable testing for emerging infectious diseases.

Communication between hospitals and isolated Aboriginal Community Health Clinics

ObjectiveThis study described the communication dynamics, identified problems and recommended changes to improve patient follow-up and communication between Royal Darwin Hospital (RDH) and isolated Aboriginal community health clinics (CHC) in the Northern Territory (NT). MethodIn 1995, staff interviews were conducted and an audit of isolated Aboriginal patients' RDH discharge summaries (DS). ResultsEighteen per cent of RDH DSs never arrived in CHCs. DSs were often prepared late and more likely to be in CHC records if written on time and if the referral source was specified. Interviews revealed discontent between CHCs and RDH regarding: communication, DS documentation, the supply of discharge medication, as well as different hospital and community perceptions of Aboriginies' reliability to carry a DS and CHC desire for patients to be given DSs at discharge. ConclusionAboriginal patients should be given a DS at discharge and resident medical officers should be educated as to the function and importance of the DS. In 18 months following this study, RDH appointed unit-based Aboriginal health workers and a policy was produced for written communication between hospital and CHCs, as well as a discharge planning manual for Aboriginal communities. ImplicationsProjects investigating communication between hospitals and isolated Aboriginal clinics and patient follow-up may result in significant policy changes concerning these processes.

Investigation of a cluster of Staphylococcus aureus invasive infection in the Top End of the Northern Territory

Staphylococcus aureus invasive infection remains a serious condition associated with considerable morbidity and mortality. Following notification of five cases at Royal Darwin Hospital (RDH), we searched for related cases, determined their epidemiological characteristics and attempted to identify the source of this apparent cluster. We reviewed RDH microbiology records between June 1996 and April 1997 for S. aureus isolates with similar antibiograms to notified cases. We used antibiotic resistance patterns, bacteriophage typing and two molecular typing techniques to subtype implicated isolates. Hospital records were reviewed for admission details and associated costs were estimated. Fifty-four cluster-related isolates occurred in 47 separate presentations. The peak incidence was in the wet season. The most important risk factor for staphylococcal invasive infection was the presence of skin sores/scabies in 17/54 cases (31%), followed by intravascular line use in 14/54 (26%), open trauma in 11/54 (20%), underlying end stage renal failure and alcoholism each in ten of 54 (18%). The mean admission length was 30 days and antibiotics were given for an average of 23 days. Death due to S. aureus infection occurred in eight of 47 (17%) presentations. S. aureus pneumonia was community acquired in 12/13 patients (92%) and six of 13 (46%) died. Ten of 13 (80%) pneumonia patients had at least one other focus of S. aureus infection. The cost of antibiotics and hospital bed per presentation was approximately $16,000. Presentations with skin sores/scabies cost considerably more ($31,000). No common epidemiologic features were found for community or hospital acquired cases. Considerable mortality and cost was attributable to cases of S. aureus invasive infection during this cluster; particularly those with community acquired pneumonia or skin sores/scabies. Staphylococcal antibiotic cover should be considered early for unwell patients presenting to hospital with pneumonia and other signs of potential S. aureus infection. It is appropriate to target public health efforts to prevent skin sores and to provide adequate treatment when they occur.

The casemix system of hospital funding can further disadvantage Aboriginal children.

The Northern Territory Health Service implemented a casemix system of hospital funding in 1996 using national averages and national cost weights as benchmarks for length of stay and funding. Clinicians and health administrators were concerned about the potential of this model to impair health service delivery, especially to children of Aboriginal or Torres Strait Islander (ATSI) descent, whose current poor health has been well described. Data were collected on children aged under 10 years who were discharged from the Royal Darwin Hospital between 1 July 1991 and 30 June 1996 and assigned one of four DRGs (simple pneumonia, bronchitis and asthma, gastroenteritis, nutritional and metabolic disorders). Data collected included age, sex, ethnicity, duration of hospital stay, location of residence and presence of comorbidities. There were significant differences in the proportion of children with multiple comorbidities between ATSI and non-ATSI children, as well as between rural- and urban-dwelling ATSI children. A higher proportion of ATSI compared with non-ATSI children had prolonged hospital stays (22.6% v. 1.5%), with the variables influencing length of stay in ATSI children including "age < 2 years", "living in a remote area", and "presence of two or more comorbidities". These results confirm clinical impressions about disease patterns and length of hospital stay in ATSI children, and highlight the problems of imposing a casemix classification system for a "typical" Australian population on a region with a high proportion of people of ATSI descent.

Screening for renal disease and other chronic diseases in Aboriginal adults and preliminary experience of a medical intervention program

NephrologyVolume 4, Issue s2 p. S90-S95 Free Access Screening for renal disease and other chronic diseases in Aboriginal adults and preliminary experience of a medical intervention program Wendy HOY, Corresponding Author Wendy HOY Royal Darwin Hospital, Territory Health Service, Darwin, and Aboriginal Renal Disease Programme, Menzies School of Health Research, Casuarina, Northern Territory, Australia Dr Wendy Hoy, Principal Research Fellow, Menzies School of Health Research, PO Box 41096, Casuarina NT 0811, Australia. Email: wendy@menzies.su.edu.auSearch for more papers by this author Wendy HOY, Corresponding Author Wendy HOY Royal Darwin Hospital, Territory Health Service, Darwin, and Aboriginal Renal Disease Programme, Menzies School of Health Research, Casuarina, Northern Territory, Australia Dr Wendy Hoy, Principal Research Fellow, Menzies School of Health Research, PO Box 41096, Casuarina NT 0811, Australia. Email: wendy@menzies.su.edu.auSearch for more papers by this author First published: 28 March 2007 https://doi.org/10.1111/j.1440-1797.1998.tb00481.xCitations: 12AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume4, Issues2September 1998Pages S90-S95 ReferencesRelatedInformation

Evaluation of PCR for diagnosis of melioidosis.

Previously published PCR-based diagnostic tests for melioidosis were evaluated for clinical usefulness. A Burkholderia pseudomallei 16S rRNA-derived primer set had a sensitivity approaching 100% for clinical samples from 22 culture-confirmed cases of melioidosis and enabled diagnosis of 3 culture-negative cases. However, samples from 10 of 30 inpatients from Royal Darwin Hospital with other diagnoses were positive by PCR, giving a specificity of 67% and a positive predictive value of only 70%. Although there are a number of intriguing possible explanations for our results, concerns of inappropriate therapy resulting from a positive result by PCR have led us to forgo the advantage of rapid PCR diagnosis for melioidosis until a better system is validated.

Clinical experience and outcomes of community-acquired and nosocomial methicillin-resistant Staphylococcus aureus in a northern Australian hospital

Methicillin-resistant Staphylococcus aureus (MRSA) is a well-recognized cause of hospital-acquired sepsis. We reviewed the clinical features of a new variant of community-acquired MRSA originally described from the Kimberley region of northern Western Australia (WA MRSA). This strain has become an increasing cause of community- and hospital-acquired sepsis at Royal Darwin Hospital (RDH) in the Northern Territory, especially in Aboriginal Australians from remote communities. Fifty percent of WA MRSA was community-acquired, with 76% in Aboriginals. Like the MRSA from eastern Australia (EA MRSA), WA MRSA commonly caused skin sepsis but was less likely to cause respiratory or urinary infections compared with EA MRSA. Twelve out of 125 (9·6%) WA MRSA and 7/93 (7·5%) EA MRSA infections were septicaemias. Septicaemia due to WA MRSA occurred in adult medical patients, especially those with temporary haemodialysis catheters, while EA MRSA septicaemia occurred throughout the hospital. Aboriginal people were more likely to develop both community- and hospital-acquired WA MRSA septicaemia [overall relative risk (RR) 12·3 (95% CI 3·7–40·7)]. Control of WA MRSA requires policies to reduce transmission in both hospitals and communities. Community-based control programmes need support for individual patient management, improved housing and hygiene, control of skin sepsis and appropriate use of antibiotics, especially in rural Aboriginal communities in northern Australia.

Risk factors for aboriginal low birthweight, intrauterine growth retardation and preterm birth in the Darwin Health Region.

Risk factors for Aboriginal low birthweight (< 2500 g), preterm birth (< 37 weeks' gestation) and intrauterine growth retardation (under the tenth percentile of Australian birthweights for gestational age) were examined in 503 live-born singletons recorded as born to an Aboriginal mother and routinely delivered at the Royal Darwin Hospital between January 1987 and March 1990. Infants born to mothers with body mass index less than 18.5 kg/m2 had five times the risk of having low birthweight and 2.5 times the risk of intrauterine growth retardation. Population-attributable risk percentages suggest that 28 per cent of low birthweight and 15 per cent of growth retardation could be attributed to maternal malnutrition. Risk percentages for maternal smoking of more than half a packet of cigarettes a day were 18 per cent for low birthweight and 10 per cent for growth retardation. For growth retardation, 18 per cent could be attributed to a maternal age under 20 years. Risk factors for preterm birth were predominantly obstetric: the population-attributable risk percentage for pregnancy-induced hypertension was 26 per cent and for other obstetric conditions was 16 per cent. For Aboriginal births in the Darwin Health Region, maternal malnutrition and smoking are key elements in the prevention of low birthweight and intrauterine growth retardation. Teenage pregnancy is an important risk for intrauterine growth retardation, and pregnancy-induced hypertension is a risk for preterm birth.

A profile of inpatient STD-related pelvic inflammatory disease in the Top End of the Northern Territory of Australia.

To obtain a profile of inpatient STD-related pelvic inflammatory disease (PID) in the Top End of the Northern Territory. Review of case records. The Royal Darwin Hospital, the tertiary referral centre for the Top End, during the three years from June 1991 to May 1994. All admissions with a diagnosis of STD-related PID. The presentation and incidence of STD-related PID in Aboriginal and non-Aboriginal women. PID was the reason for 14% of admissions of Aboriginal women and 2% of non-Aboriginal women. Of 175 episodes of PID in 169 patients admitted over the three years of the study, 41 (23%) had gonorrhoea, 64 (37%) had chlamydia and 7 (4%) had both organisms isolated on genital swab. Aboriginal women were more than twice as likely to have gonorrhoea (38% versus 18%; risk ratio, 2.12; 95% confidence interval, 1.27-3.53) as non-Aboriginal women. Median time from first symptoms to presentation was six days. All gonococcal isolates were penicillin susceptible. STD-related pelvic inflammatory disease is an important problem among women in the Top End of the Northern Territory. As PID is a preventable illness, further measures aimed at prevention and earlier, more effective treatment of STDs that cause PID are urgently required.

Malnutrition and microcephaly in Australian aboriginal children.

To examine the association between malnutrition and microcephaly in the first two years of life. Cross-sectional study. Royal Darwin Hospital (a tertiary referral centre); 157 of 165 previously studied Aboriginal children aged under two years who were admitted with diarrhoea between May 1990 and April 1991. Birth weight, birth length, birth head circumference, admission head circumference and admission nutritional status were examined. Nutritional status was categorised according to World Health Organization (WHO) criteria for wasting (thinness) and stunting (shortness). Microcephaly on admission was defined as a head circumference less than the second percentile on Australian reference charts. Small-for-gestational-age (SGA) and birth microcephaly were defined as being less than the tenth percentile for an Australian hospitalised population, corrected for gestational age at confinement. Low birth weight (LBW) was defined as less than 2500 g. Microcephaly on admission. Of the 157 children, 76 (48%) were wasted, 36 (23%) stunted and 37 (24%) microcephalic on admission. A total of 26 (17%) children had been of LBW, 17 (11%) SGA and 21 (13%) microcephalic at birth. On univariate analysis, microcephaly on admission was associated with wasting (crude odds ratio [OR], 3.91; 95% confidence interval [CI], 1.6-9.7; P < 0.005), but not stunting. There were no significant associations between microcephaly on admission and LBW, being SGA, microcephaly at birth, age or sex. With multivariate analysis, birth head circumference was significantly associated with microcephaly on admission (adjusted OR, 3.62; 95% CI, 1.28-10.23; P < 0.05), as was wasting (adjusted OR, 4.38; 95% CI, 1.88-10.20; P < 0.001). Wasting was significantly associated with microcephaly, independent of intrauterine growth retardation (as measured by being SGA) and LBW. As malnutrition in critical periods of both intra- and extrauterine development may have irreversible effects on intellectual potential and behaviour, the emphasis on improved nutrition must begin during pregnancy, and should continue in infancy and early childhood.

An 18 year clinical review of septic arthritis from tropical Australia.

A retrospective study of 191 cases of septic arthritis was undertaken at Royal Darwin Hospital in the tropical north of Australia. Incidence was 9.2 per 100,000 overall and 29.1 per 100,000 in Aboriginal Australians (RR 6.6; 95% CI 5.0-8.9). Males were affected more than females (RR 1.6; 95% CI 1.2-2.1). There was no previous joint disease or medical illness in 54%. The commonest joints involved were the knee (54%) and hip (13%). Significant age associations were infected hips in those under 15 years and infected knees in those over 45 years. Seventy two percent of infections were haematogenous. Causative organisms included Staphylococcus aureus (37%), Streptococcus pyogenes (16%) and Neisseria gonorrhoeae (12%). Unusual infections included three melioidosis cases. Polyarthritis occurred in 17%, with N. gonorrhoeae (11/23) more likely to present as polyarthritis than other organisms (22/168) (OR 6.0; 95% CI 2.1-16.7). Univariate and multivariate analysis showed the hip to be at greater risk for S. aureus than other joints. Open arthrotomy was a more successful treatment procedure than arthroscopic washout or needle aspiration.

Emerging epidemic of community-acquired methicillin-resistant Staphylococcus aureus infection in the Northern Territory.

To investigate the epidemiology of WA MRSA (the recently recognised Western Australian strains of methicillin-resistant Staphylococcus aureus) in the north of the Northern Territory (NT). Retrospective survey of data from hospital records. Royal Darwin Hospital (a tertiary referral hospital that serves the north of the NT) between January 1991 and July 1995. All inpatients with clinical MRSA infection. Incidence of MRSA infection, classification of MRSA as WA or EA (Eastern Australian) based on antibiotic susceptibility, patient demographic details (age, sex, ethnicity, region of residence), source of infection (nosocomial or community-acquired). There were 125 WA MRSA and 93 EA MRSA infections, comprising 7% of all S. aureus infections. The incidence of WA MRSA infections consistently increased, while that of EA MRSA initially fell and then increased. All EA MRSA infections were nosocomial, while 50% of WA MRSA infections were community-acquired. Rates of WA MRSA infections were highest in patients from the west region of the NT, adjacent to the Kimberley region of Western Australia (WA). Community-acquired WA MRSA infections were more likely to affect Aboriginals than non-Aboriginals (relative risk [RR], 25.86; 95% confidence interval [CI], 12.51-53.47, based on population data; RR, 15.43; 95% CI, 7.85-30.32, based on admission data), as were nosocomial EA MRSA infections (RR, 2.54; 95% CI, 1.44-4.47, based on population data; RR, 2.30; 95% CI, 1.52-3.46, based on admission data). Changes in the epidemiology of MRSA infection in the north of the NT are consistent with the hypothesis that community-acquired WA MRSA spread into and across the NT from the Kimberley region of WA. Alternatively, crowded living conditions, hygiene difficulties and increasing use of broad spectrum antibiotics may have led to independent emergence of WA MRSA in both regions. Current infection control policies and their use in rural Aboriginal communities must be reassessed.

Chromoblastomycosis: A retrospective study of six cases at the royal darwin hospital from 1989 to 1994

Chromoblastomycosis, a localized chronic cutaneous and subcutaneous infection of the skin caused by pigmented fungi, is most common in the world's tropical and subtropical zones. The condition rarely occurs in Australia. We present 6 cases of chromoblastomycosis seen at the Royal Darwin Hospital, Northern Territory, from 1989 to 1994 and affecting predominantly male Caucasians ranging from 38 to 71 yrs of age. Clinically the lesions were verrucous or nodular. They mimicked basal or squamous cell carcinoma, nevi or solar keratoses. Histopathologic findings were nonspecific. The only pathognomonic finding was the presence of brown spores or sclerotic bodies within granulomata or within microabscesses in the skin.