Point-of-care ultrasonography-An essential skill for medical graduates?

The recent proliferation of point-of-care ultrasonography (POCUS) in the clinical practice of many medical specialties has exposed persistent barriers to education, training and standardisation. Specialist training curriculums are already overwhelming, having grossly insufficient time available for the specialist trainees and for the small number of available trainers alike to incorporate POCUS into postgraduate education. The logical solution to overcome these barriers could be to incorporate basic POCUS education and training into the undergraduate university curriculums, introducing longitudinal integration with other relevant medical sciences. The Australasian Society of Ultrasound in Medicine already has well-established educational programmes in POCUS with standardised assessment of competency, which could potentially offer the basis for symbiosis with the Australian and New Zealand medical schools.

Novel student roles in health care delivery: An example emerging from the COVID-19 health care crisis in 2021

In 2021, the rapid rise in COVID-19 infections put overwhelming demand on health care services. It was recognised that patients could be managed in the community if an appropriate monitoring service existed. Medical students were recruited for roles that combined technology, teamwork and clinical skills. This is an example of how novel roles can provide solutions in times of health care crises.

Lifting the curtains of silence: Patient perceptions towards needs and responsibilities in contributing to the prevention of healthcare-associated infections and antimicrobial resistance

BACKGROUND

Beyond the use of policy and system-focused approaches, it has been established globally that patients can play a role in enhancing the health care landscape. However, efforts to meaningfully translate patient engagement strategies that promote participation by hospitalized patients in relevant infection prevention and antimicrobial stewardship activities have not yet been realized. This study mapped the key factors acting as barriers and facilitators of patient engagement using a theoretical framework to identify potential new approaches to promote engagement.

METHODS

Semistructured interviews were conducted with 36 patients from 3 major hospitals in Sydney, Australia, in 2019. Transcripts were inductively analyzed, with the resulting themes categorized into the components of the Capability-Opportunity-Motivation-Behavior model.

RESULTS

The themes regarding barriers to patient engagement with relevant infection prevention and antimicrobial stewardship activities were: (1) Capability: misunderstanding and knowledge gaps about antimicrobial resistance; (2) Opportunity: strong family/patient support networks and good relationships with nursing staff provide an opportunity to support engagement; (3) Motivation: those who have some level of understanding or experience see the benefit and are most likely to engage actively.

CONCLUSIONS

Assuming patients are inclined to participate in efforts, a logical starting point would be to build awareness amongst patients and providers; however, education will not suffice. There needs to be a system and policy shift to ensure that patient engagement is recognized as a worthy endeavor.

Standardized testing and written communication improve patient understanding of beta-lactam allergy testing outcomes: A multicenter, prospective study

Background

Historical penicillin allergy is commonly reported, but the lack of standardized allergy clinic practices may diminish the ability to delabel beta-lactam allergy appropriately.

Objective

We sought to improve beta-lactam allergy testing and patient understanding of their antibiotic allergy status by standardizing testing and communication practices between 7 adult and pediatric hospital centers.

Methods

Phase 1 prospectively described the beta-lactam allergy testing practices at each center. Following this, practice was standardized to achieve a defined panel of skin testing reagents, pro forma result letters for patients and referring doctors, and provision of medical alert jewelry to those with confirmed allergy. Testing outcomes and patient perception regarding allergy status 8 weeks postassessment were compared before (phase 1) and after standardization (phase 2). Primary outcomes were the percentage of participants delabeled after testing, and concordance rates between participant perception of their allergy status and their status as determined by the treating physician at 8-week follow-up.

Results

Of 195 adult and pediatric participants (median age, 50 years; 21.5% <18 years; 36.9% males), 75% were delabeled of their beta-lactam allergy. No patient experienced anaphylaxis related to any beta-lactam delabeling testing. In phase 1, 75% of participants received written results, 52% were informed verbally, and 48% received results in more than 1 form. All phase 2 participants received written results (P < .01), 61% received verbal results from a physician as well (P > .05). At 8-week follow-up, 54% of phase 1 participants had concordant perceptions of their allergy status as the testing team versus 91.6% in phase2 (P < .001). Of the 17 participants who were delabeled and treated with a beta-lactam antibiotic during the 8-week follow-up period, there were no reported allergic reactions, although 1 participant experienced anaphylaxis following exposure to amoxicillin-clavulanic acid 1 year after delabeling.

Conclusions

Standardization of testing and written patient information improved short-term patient perception of beta-lactam allergy status.

Medical teachers' experience of emergency remote teaching during the COVID-19 pandemic: a cross-institutional study

BACKGROUND

The COVID-19 pandemic and the consequent social distancing measures caused unprecedented disruption for medical and healthcare education. This study examined medical teachers' experience with emergency remote teaching during the pandemic and their acceptance of online teaching after the pandemic.

METHODS

In this sequential mixed methods study, online surveys were disseminated to teachers (n = 139) at two Asia-Pacific medical schools to evaluate their experience with emergency remote teaching during the pandemic. Subsequently, in-depth interviews were conducted with teachers from both institutions (n = 13). Each interviewee was classified into an adopter category based on Rogers' Diffusion of Innovations Theory. Interview transcripts were analyzed thematically, and the descriptive themes were mapped to broader themes partly based on the Technology Acceptance Model and these included: (i) perceived usefulness of online teaching, (ii) perceived ease of delivering online teaching, (iii) experience with institutional support and (iv) acceptance of online teaching after the pandemic.

RESULTS

Our participants described accounts of successes with their emergency remote teaching and difficulties they experienced. In general, most participants found it difficult to deliver clinical skills teaching remotely and manage large groups of students in synchronous online classes. With regards to institutional support, teachers with lower technological literacy required just-in-time technical support, while teachers who were innovative in their online teaching practices found that IT support alone could not fully address their needs. It was also found that teachers' acceptance of online teaching after the pandemic was influenced by their belief about the usefulness of online teaching.

CONCLUSIONS

This study demonstrated that our participants managed to adapt to emergency remote teaching during this pandemic, and it also identified a myriad of drivers and blockers to online teaching adoption for medical teachers. It highlights the need for institutes to better support their teaching staff with diverse needs in their online teaching.

Predictors of treatment success following peri-prosthetic joint infection: 24-month follow up from a multi-center prospective observational cohort study of 653 patients

Background

Periprosthetic joint infection (PJI) is a devastating condition and there is a lack of evidence to guide its management. We hypothesized that treatment success is independently associated with modifiable variables in surgical and antibiotic management.

Methods

The is a prospective, observational study at 27 hospitals across Australia and New Zealand. Newly diagnosed large joint PJIs were eligible. Data were collected at baseline and at 3, 12, and 24 months. The main outcome measures at 24 months were clinical cure (defined as all of the following: alive, absence of clinical or microbiological evidence of infection, and not requiring ongoing antibiotic therapy) and treatment success (clinical cure plus index prosthesis still in place).

Results

Twenty-four-month outcome data were available for 653 patients. Overall, 449 patients (69%) experienced clinical cure and 350 (54%) had treatment success. The most common treatment strategy was debridement and implant retention (DAIR), with success rates highest in early postimplant infections (119 of 160, 74%) and lower in late acute (132 of 267, 49%) and chronic (63 of 142, 44%) infections. Selected comorbidities, knee joint, and Staphylococcus aureus infections were independently associated with treatment failure, but antibiotic choice and duration (including rifampicin use) and extent of debridement were not.

Conclusions

Treatment success in PJI is associated with (1) selecting the appropriate treatment strategy and (2) nonmodifiable patient and infection factors. Interdisciplinary decision making that matches an individual patient to an appropriate management strategy is a critical step for PJI management. Randomized controlled trials are needed to determine the role of rifampicin in patients managed with DAIR and the optimal surgical strategy for late-acute PJI.

It's what you do, not the way you do it - online versus face-to-face small group teaching in first year medical school

BACKGROUND

Major disruptions imposed on medical education by the COVID-19 pandemic and the rapid shift to online teaching in medical programs, necessitated need for evaluation of this format. In this study we directly compared knowledge outcomes, social outcomes, and wellbeing of first year student small group teaching in either face to face (f2f) or online format.

METHODS

At the end of the first course of our medical program, students were invited to participate in an online questionnaire with 10 quantitative items and 1 qualitative item. These were analysed using Factor Analysis Pattern Matrix and linear regression to group items and assess relatedness. Qualitative responses were thematized using Qualtrics software (Qualtrics, Provo, UT, USA). Summative assessment results were compared, both between current cohorts to historical cohorts.

RESULTS

From a cohort of 298 students there was a 77% response rate. Overall, there were no differences in knowledge gains, either between groups or when compared to historical cohorts. Questionnaire items fell reliably into groups that related to either learning outcomes, social outcomes, or wellbeing. Independent T tests showed that format for teaching (online versus f2f) had an impact on social outcomes but no direct impact on learning outcomes. Linear regression revealed that the social outcomes have a direct impact on wellbeing and almost the double the impact on learning outcomes than mode of learning i.e.. F2f or online (β = .448 and β = .232 respectively).

CONCLUSION

In this study, we were able to show with statistical strength that social outcomes for students such as engaging with peers and facilitator, contributing to the group, and making friends have a direct impact on wellbeing and indirectly impact learning outcomes (such as motivation, satisfaction, integration of knowledge). In a rapidly changing educational landscape, in our opinion, it is vital that these aspects are a focus of design and delivery of medical education. The data from this study supports the notion that activity design and the expertise of the teacher in facilitating the small group activities, has greater impact than the mode of educational delivery itself on students' learning processes.

Review of ethics teaching in undergraduate medical education

OBJECTIVE

To provide an overview of existing literature regarding ethics in undergraduate medical education around the world, and to identify gaps in literature for recommending areas for future research.

METHODS

The scoping review was conducted in March 2016. PubMed and Web of Science search engines were used to identify English language literature on ethics in undergraduate medical education published over the preceding 20 years. Google search was used for grey literature. Two reviewers independently screened eligible studies for final study selection and review. Descriptive analysis of data was performed with mutual consensus.

RESULTS

Of the 199 items located, 56(28%) were included; 37(33%) of 112 studies, and 19(22%) of 87 pieces of grey literature. Papers covered almost all regions of the world, including North and South America, Europe, Africa, and different Asian regions like Middle East, central, south-east and far east. The analysis identified several curriculum designs and teaching methods used for ethics education.

CONCLUSIONS

The review identified gaps in evidence that required further research. These areas include theoretical underpinning of ethics curriculum, role of educators, standardisation and validation of teaching and learning strategies, and relevance to cultural context in the development and delivery of ethics curriculum, especially in Asian regions.

Systematic development and refinement of a contextually relevant strategy for undergraduate medical ethics education: a qualitative study

BACKGROUND

Delivery of medical ethics education is complex due to various reasons, compounded by the context-dependent nature of the content. The scarcity of relevant resources in the contexts of some developing countries adds a further layer of difficulty to ethics education in these contexts. We used a consultative approach with students, teachers and external experts to develop a practical approach to medical ethics education. This study aimed to develop and refine a contextually relevant approach to ethics education in the region of Saudi Arabia.

METHODS

The study utilised an explorative qualitative methodology to seek views of students and faculty of Rabigh Faculty of Medicine, Saudi Arabia, and international experts in the field of ethics and education to review and enhance a new ethics learning strategy which included a workbook-based tool. Three focus groups with 12 students, in-depth interviews with four faculty members and qualitative feedback from eleven external experts enabled the study participants to objectively critique the WBEL and provide feedback to enhance its quality. Thematic content analysis of the data was done to draw inferences which were used to refine the educational strategy.

RESULTS

The analysis generated twenty-one sub-themes within four main themes: design features, content, teaching methods and assessment. These findings helped to design the educational strategy to improve its effectiveness in the given context.

CONCLUSION

The study drew on the views of students, faculty and external experts to systematically develop a novel approach to ethics education for countries like Saudi Arabia. It also demonstrated the use of the consultative approach for informing a culturally relevant educational strategy in the Middle East context.

Prevalence of antibiotic allergy labels and their consequences in people presenting to a teaching hospital Emergency Department; a retrospective chart review

BACKGROUND

Antibiotic allergy labels have a direct impact on individual patient care and on the consumption of broad-spectrum antibiotics.

OBJECTIVE

Our aim was to establish the prevalence of antibiotic allergies and to determine whether patients with documented antibiotic allergy labels received guideline concordant antimicrobial therapy. Additionally we wanted to evaluate the quality of allergy documentation in the medical record.

METHODS

Prospective audit of all patients presenting to the Emergency Department of an adult teaching hospital in Sydney over a 4 month period. Documented allergy labels, diagnoses, antibiotic administration and outcomes were recorded. Appropriateness of antibiotic choice was based on the Australian National Antimicrobial Prescribing Survey.

RESULTS

9.9% of presentations had at least one antibiotic allergy recorded. Significantly more women than men had antibiotic allergies documented. One third of patients with documented antibiotic allergies were prescibed inappropriate antibiotic therapy and some had significant adverse events.

CONCLUSIONS

The documentation of antibiotic allergy labels and choice of antibiotic treatment can be significantly improved. Strategies to safely de-label people with documented allergies who are not truly allergic need to be implemented.

CLASSIE teaching - using virtual reality to incorporate medical ethics into clinical decision making

BACKGROUND

Teaching medical ethics (ME) in the clinical environment is often difficult, uncalibrated and medical students get variable exposure to skilled educators. Explicit discussion of ethical dimensions of patient management is often neglected, as clinical teachers may feel inadequately skilled to do this.

METHODS

We developed a suite of online modules. Each consisted of a clinical scenario filmed using virtual reality (VR) technology, linked to an adaptive, interactive, online tutorial which explicitly discussed the relevant ethical issues and guidelines. These were embedded in clinical placements of students to encourage the transfer of knowledge from these modules to clinical skill competency. We conducted a pilot study to evaluate these modules which examined student engagement, knowledge gains (self-perceived and measured) and user experience. We also reviewed reflections to assess the incorporation of these modules and transfer of knowledge into the clinical learning and skill development of the students.

RESULTS

Engagement and self-perceived knowledge gains were extremely high. Students found these modules realistic, interesting and helpful. The measured knowledge gains (module exit quiz) were moderate. User experience was positive overall, although students were intolerant of any technical glitches. There was mixed feedback on whether the VR aspect of the clinical scenarios added value. Student reflections showed high level incorporation of these modules into clinical practice of the students and evidence of knowledge transfer (level 3 Kirkpatrick model of evaluation) in over ¾ of students.

CONCLUSIONS

This study showed that the use VR clinical scenarios combined with interactive online learning modules resulted in demonstrable high-level student engagement and learning gains in medical ethics and transfer of knowledge to clinical application. It standardised and ensured the student experience of high-quality educational deliverables in clinical years of medical education. This use of VR and online technology can be adapted for use in many areas of the medical curricula where we need to ensure the delivery of well calibrated, high quality, educational deliverables at scale for students.

How COVID-19 has pushed us into a medical education revolution

The COVID‐19 pandemic has had a profound effect on society and higher education in Australia. In just a few weeks, entire courses have been re‐structured and are now delivered online. The need to adapt rapidly has prompted many innovative changes that will ultimately have long‐term benefits for medical education in Australia and New Zealand.

Clinical Characteristics, Etiology, and Initial Management Strategy of Newly Diagnosed Periprosthetic Joint Infection: A Multicenter, Prospective Observational Cohort Study of 783 Patients

Background

Periprosthetic joint infection (PJI) is a devastating complication of joint replacement surgery. Most observational studies of PJI are retrospective or single-center, and reported management approaches and outcomes vary widely. We hypothesized that there would be substantial heterogeneity in PJI management and that most PJIs would present as late acute infections occurring as a consequence of bloodstream infections.

Methods

The Prosthetic joint Infection in Australia and New Zealand, Observational (PIANO) study is a prospective study at 27 hospitals. From July 2014 through December 2017, we enrolled all adults with a newly diagnosed PJI of a large joint. We collected data on demographics, microbiology, and surgical and antibiotic management over the first 3 months postpresentation.

Results

We enrolled 783 patients (427 knee, 323 hip, 25 shoulder, 6 elbow, and 2 ankle). The mode of presentation was late acute (>30 days postimplantation and <7 days of symptoms; 351, 45%), followed by early (≤30 days postimplantation; 196, 25%) and chronic (>30 days postimplantation with ≥30 days of symptoms; 148, 19%). Debridement, antibiotics, irrigation, and implant retention constituted the commonest initial management approach (565, 72%), but debridement was moderate or less in 142 (25%) and the polyethylene liner was not exchanged in 104 (23%).

Conclusions

In contrast to most studies, late acute infection was the most common mode of presentation, likely reflecting hematogenous seeding. Management was heterogeneous, reflecting the poor evidence base and the need for randomized controlled trials.

Cluster of invasive Mycobacteria chimaera infections following cardiac surgery demonstrating novel clinical features and risks of aortic valve replacement

There is a global outbreak of infections due to Mycobacterium chimaera associated with cardiac surgery. The most serious infections involve prosthetic material implantation, and all have followed surgical procedures involving cardiopulmonary bypass. We describe a cluster of four cases following cardiac surgery at a tertiary referral centre in Sydney, Australia. We report novel clinical findings, including haemolysis and kidney rupture possibly related to immune reconstitution inflammatory syndrome. The positive effect of corticosteroids on haemodynamic function in two cases and the failure of currently recommended antimicrobial therapy to sterilise prosthetic valve material in the absence of surgery despite months of treatment are also critically examined. Positron emission tomography was positive in two cases despite normal transoesophageal echocardiograms. The proportion of cases with M. chimaera infection after aortic valve replacement (4/890, 0.45%; 95% confidence interval 0.18-1.15%) was significantly higher than after all other cardiothoracic surgical procedures (0/2433, 0%; 95% confidence interval 0-0.16%).

Managing diabetic foot infections: a survey of Australasian infectious diseases clinicians

Background

Diabetic foot infections (DFI) present a major morbidity, mortality and economic challenge for the tertiary health sector. However, lack of high quality evidence for specific treatment regimens for patients with DFIs may result in inconsistent management. This study aimed to identify DFI caseload proportion and patterns of clinical practice of Infectious Diseases (ID) Physicians and Trainees within Australia and New Zealand.

Methods

A cross-sectional online survey of Australian and New Zealand ID Physicians and Trainees was undertaken, to estimate the overall ID caseload devoted to patients with DFIs and assess clinicians' management practices of patients with DFIs.

Results

Approximately 28% (142/499) of ID Physicians and Trainees from Australia and New Zealand responded to the survey. DFI made up 19.2% of all ID consultations. Involvement in multidisciplinary teams (MDT) was common as 77.5% (93/120) of those responding indicated their patients had access to an inpatient or outpatient MDT. Significant heterogeneity of antimicrobial treatments was reported, with 82 unique treatment regimens used by 102 respondents in one scenario and 76 unique treatment regimens used by 101 respondents in the second scenario. The duration of therapy and the choice of antibiotics for microorganisms isolated from superficial swabs also varied widely.

Conclusions

Patients with DFIs represent a significant proportion of an ID clinician's caseload. This should be reflected in the ID training program. Large heterogeneity in practice between clinicians reflects a lack of evidence from well-designed clinical trials for patients with DFI and highlights the need for management guidelines informed by future trials.

Antibiotic allergy labels-the impact of taking a clinical history

BACKGROUND

Many patients admitted to hospital have an antibiotic allergy (AAL) documented in their medical record. In many of these, the reaction is not a hypersensitivity reaction or may no longer be relevant. Despite this, the label adversely affects patient care directly in terms of antibiotic selection, and indirectly in terms of patient costs and the development of antimicrobial resistance.

AIMS

To estimate the prevalence of AALs in a cohort of hospitalised patients, to investigate the feasibility of de-labelling through re-challenge based solely upon clinical grounds.

DESIGN

This is a cross-sectional study conducted over a 6-month period on adult inpatients. An allergy history was taken from each patient and compared with medical record data regarding allergy. Antibiotic selection data were collected (if relevant). It was then determined whether immediate de-labelling was appropriate, if direct provocation test (DPT) could be relatively safely performed, and if antibiotic selection was appropriate.

RESULTS

Three thousand eight hundred and fifty five patients were screened, 553 (14.35%) had an AAL, and 352 were interviewed. There were 426 AALs; 276 (64.8%) towards a penicillin. After taking a detailed clinical history of the type of reaction, approximately 20% could be immediately de-labelled and educated (non-allergic, non-severe reactions) and another 38% with either a definite or vague history of mild cutaneous reaction would be suitable for an attempt at clinical de-labelling DPT.

CONCLUSIONS

These simple measures to 'de-label' patients appropriately, would increase the quality of care of this group known to have higher costs, infection with more resistant bacteria and worse health outcomes that 'non-labelled' patients.

Antibiotic Allergies – Is De-labeling Based on Clinical History Feasible?

Background

Up to 25% of patients admitted to hospital have an antibiotic allergy label (AAL), most of which are towards penicillin. However, up to 90% of patients who claim to be allergic to penicillin are actually able to tolerate them1. Whilst skin testing is safe and efficacious in de-labeling patients with a penicillin allergy label, it is usually not widely available. Therefore, we investigated the feasibility of de-labeling based solely upon clinical grounds. Quality of allergy documentation and subsequent antibiotic use was also assessed.

Methods

This was a cross-sectional study assessing all patients admitted to a tertiary referral teaching hospital over a 5-month period in 2016. All newly admitted patients were prospectively screened for the presence of an antibiotic allergy documented in their electronic medical record. Unless unable to participate, patients were interviewed regarding the detailed nature of their antibiotic allergy. Information regarding allergy documentation, medical condition and antibiotic use was obtained from medical records.

Results

3855 patients were screened, 553 (14.35%) had an AAL, and 352 were interviewed. There were 426 allergies, 276 (64.8%) towards a penicillin. Only 52% of patients had a convincing history consistent with antibiotic allergy, and 48% of these were mild cutaneous reactions. It was felt that de-labeling and direct re-challenge would be relatively safe in 70% (298/42) of AALs (if the mild cutaneous allergic group were included). In patients who were prescribed antibiotics during study admission, 25.6% (41/160) of antibiotic prescriptions in our cohort were found to be inappropriate in patients with AALs.

Conclusion

Direct re-challenge based upon clinical grounds appears to be a feasible clinical option in many patients with AALs and would allow de-labeling of these patients. The major barriers continue to be patient acceptance and risk of severe adverse reactions. Our study also found that major improvements could be made in the specific documentation of allergy and also in selection of guideline-recommended alternate antibiotics.

1. Joint Task Force on Practice Parameters. Drug Allergy: An Updated Practice Parameter. Ann Allergy Asthma Immunol. 2010; 105(4): p. 259–273.

Disclosures

All authors: No reported disclosures.

Invasive pneumococcal disease following adult allogeneic hematopoietic stem cell transplantation

BACKGROUND

Allogeneic hematopoietic stem cell transplantation (alloHSCT) recipients are at high risk of invasive pneumococcal disease (IPD). We investigated the incidence and risk factors of IPD in alloHSCT recipients from 4 regional transplant centers over an 11-year period. This study aimed to inform future improvements in post-transplant care.

METHODS

We conducted a retrospective nested 1:2 case-control study in patients aged ≥18 years who underwent alloHSCT between 2001 and 2011 in 4 major allogeneic transplant centers. Controls were matched with IPD cases on the basis of conditioning intensity and donor relationship (related or unrelated). Demographics and clinical characteristics of cases and controls were summarized. Univariate analysis of risk factors in matched case-control sets, and multivariate conditional logistic regression to control for confounding, were performed.

RESULTS

In 23 alloHSCT recipients, 26 IPD episodes were identified. The cumulative incidence over 11 years was 2.3% (95% confidence interval [CI] 1.45-3.15) and the incidence density 956 per 100,000 transplant years of follow-up (95% CI 580-1321). Multivariate risk factor analysis and backwards elimination showed a significant positive association between mycophenolate mofetil (MMF), hyposplenism/asplenia, and IPD, whereas trimethoprim-sulfamethoxazole (TMP/SMX) prophylaxis for Pneumocystis jirovecii pneumonia (PJP) was associated with lower odds of IPD cases. Of alloHSCT recipients with IPD, 38.5% required intensive care, and, of deaths documented in cases over the period of review, 30% were attributable to IPD. Serotypes causing IPD matched currently available vaccines in 15/22 (68.1%) episodes.

CONCLUSIONS

The incidence of IPD in alloHSCT recipients is an important cause of morbidity and mortality, with rates of disease being many fold higher than the general population. Patients with evidence of hyposplenism/asplenia define a high-risk group in the alloHSCT population for IPD, and the independent association with IPD and MMF in the adjusted model from this study requires further evaluation. The occurrence of post-transplant IPD may be reduced by measures such as vaccination with both 13-valent and 23-valent pneumococcal vaccines. TMP/SMX prophylaxis for the prevention of PJP may offer incidental protection against IPD in alloHSCT recipients.

Travel and pregnancy: an infectious diseases perspective

Increasing numbers of women are choosing to travel during pregnancy. In the presence of an altered immune state, exposure to certain microbes can be particularly harmful. We have undertaken a review of the literature in order to provide strategies to minimize the infectious disease risks of pregnant travel. Included is a discussion of common immunizing agents and their safety in pregnancy.

Ethical issues in pandemic planning

In the event of an influenza pandemic, many ethical issues will arise in terms of health risks, resource allocation, and management decisions. Planning decisions may be controversial, such as rationing of antivirals, resource allocation (including hospital beds and vaccinations), occupational risk, rostering of staff, responsibilities of health care workers, quarantine measures, and governance issues. A clear ethical framework is needed to enable understanding of the decision-making process and optimise acceptance of decisions by health care workers and other members of an affected community. Planning decisions need to start being examined now, and will require input from a broad group of experts: health care providers, infrastructure managers, lawyers, ethicists, public health physicians, and community members. The process will need to be open, honest and dynamic.

How far does a doctor's 'duty of care' go?

It is a long-standing tradition in medicine that doctors have an ethical duty to care for all patients who fall within the scope of their skill base. This duty reflects the value system of many doctors and the type of typical dedication to their craft that has long been expected and given. The modern doctor, however, may have other additional roles -- such as those of parent, researcher, business person and many others. What about the duties that accompany these other activities and what if these duties come into conflict with the duty to care for patients? How does a doctor decide how far the duty to care for patients extends? This article explores this question of duty and discusses how the notion of the traditional doctor's duty to care may need to be amended in light of the kinds of lives that doctors now lead.

The pathology of human and murine pulmonary infection with Cryptococcus neoformans var. gattii

Human infection by Cryptococcus neoformans var. neoformans is well characterised and usually occurs in immunocompromised patients. Less is known about infection by Cryptococcus neoformans var. gattii, which usually produces disease in previously normal individuals. In two cases of human pulmonary infection by Cryptococcus neoformans var. gattii, we observed a mixed inflammatory pattern, including granulomas associated with numerous T lymphocytes and a lymphocytic interstitial pneumonitis with B lymphocytes and formation of follicles. We also established a murine model of pulmonary infection by Cryptococcus neoformans var. gattii, which reproduced most of these features. This model is likely to prove useful in studies of the pathogenesis of this infection.

Toxoplasmosis. Are cats really the source?

BACKGROUND

Toxoplasmosis is a zoonotic infection caused by the parasite Toxoplasma gondii. It would appear to be one of the commonest human infections, but is usually asymptomatic. It is only problematic if the patient is pregnant or immunosuppressed.

OBJECTIVE

To discuss the epidemiology, clinical features, diagnosis, treatment and prevention of toxoplasmosis.

DISCUSSION

Cats have long been blamed for playing a major role as the reservoir of this infection. To some extent, this is true, although contact with infected raw meat is probably a more important cause of human infection in many countries. Direct contact with pet cats is also a less common risk factor for infection than ingestion of the oocyst from faecally contaminated hands (often via soil).