Examine the nature of domestic and family violence (DFV) presentations to an ED in the Northern Territory and identify potential gaps in service delivery.Prospective descriptive study of DFV presentations in November 2021.A total of 70 presentations were identified, representing 1.2% of all presentations aged 16 years and older. Disproportionately impacted were First Nations people (90%), women (77.1%) and those aged less than 40 years (67.1%). Most (81.4%) arrived outside of business hours and only 37.1% were assessed by the social worker. Case complexity was increased by high rates of homelessness (30%), concurrent alcohol consumption (44.3%) and pregnancy (11.1% of females). More than a third (37.1%) had attended on one to four occasions in the previous 6 months with a DFV-related injury. Compared to non-DFV attendances, the median ED length of stay was approximately twice as long (456 vs 210 min), admissions rates to the ED short stay unit five times higher (25.7% vs 5.7%; P < 0.01, odds ratio [OR] = 5.7 and 95% confidence interval [CI] = 3.3-9.8) and rates of self-discharge prior to completion of care 9 times higher (12.9% vs 1.5%; P < 0.01, OR = 9.5 and 95% CI = 4.6-19.7).The data highlights the need for a 24 h trauma-informed, culturally safe and integrated service to support people experiencing DFV. This could be achieved by a specialist unit designed and staffed by First Nations health practitioners.

Suspected preterm labour (PTL) and prelabour rupture of membranes (PPROM) are common indications for aeromedical retrieval in the Top End, Northern Territory, Australia, where many women reside remotely and preterm birth (< 37 completed weeks of gestation) is common. The primary objective of this study was to determine rate of delivery during the index admission following aeromedical transfers from remote clinics to Royal Darwin Hospital for suspected PTL/PPROM.A retrospective cohort study of aeromedical transfers for suspected PTL/PPROM from 1 January 2020 to 31 July 2022 was undertaken. Transfers were identified through CareFlight, the regional air ambulance service, and complemented with data from hospital records. Clinical and sociodemographic characteristics were compared by delivery status during the index (post-retrieval) admission using parametric and non-parametric tests and multivariable linear regression analysis.238 women with singleton pregnancies were retrieved for suspected PPROM (n = 77, 32.4%) or PTL (n = 161, 67.6%), together accounting for 49.2% of all obstetric transfers (n = 483). Of 77 patients transferred for suspected PPROM, 47 (61.0%) had ruptured membranes confirmed on arrival, and 45 (95.7%) of them delivered during the index admission. None of the 30 women transferred for suspected PPROM with intact membranes on arrival delivered during the index admission. Of 161 patients transferred for suspected PTL, 13 (8.1%) had ruptured membranes confirmed on arrival, and 12 (92.3%) of them delivered during the index admission. Amongst women transferred for suspected PTL with intact membranes confirmed on arrival, 14.9% (22/149) delivered during the index admission. Prior to arrival, 120 women (50.4%) had a documented speculum examination, and 15 (6.3%) and 9 (3.8%) had cervicovaginal swab tests to assess their risks of a PPROM and PTL, respectively. Half of women who did not deliver during the index admission had received antenatal corticosteroids (n = 76).Many aeromedical retrievals for suspected PTL/PPROM did not result in delivery during the index admission. Women retrieved for suspected PPROM with intact membranes on arrival were less likely to deliver. Upskilling remote clinic staff and better point-of-care testing may reduce retrievals and unnecessary interventions. Prospective cohort studies designed to enable accurate prediction of which cases can be safely not retrieved are required.Not applicable.

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Acute gastroenteritis is a major cause of morbidity and mortality in children. The aim of this study was to explore assessment and management of children aged between 6 and 48 months presenting to the emergency department (ED) with acute gastroenteritis.This retrospective cohort study included 340 children aged 6-48 months. Data were collected by medical record audit for children presenting between 1 January and 31 December 2019.General assessments were appropriate, specific dehydration assessment, blood pressure measurement and fluid balance chart documentation could be improved. Management of children with severe or no/mild dehydration was largely compliant with current recommendations: there was variability in management of children with moderate dehydration. There were no significant differences between Australian Aboriginal and non-Aboriginal children in terms of dehydration severity and pathology abnormalities, however there were differences in management strategies.ED management of children with gastroenteritis was largely consistent with, or superior to, evidence-based recommendations. There was variability in the management of children with moderate dehydration and Australian Aboriginal children but it is unclear whether this is suboptimal or patient specific care. This study has highlighted areas for further research in this unique context.

During a paediatric emergency, it is often impractical to weigh a child. Many resuscitative measures require a child's weight; therefore, estimation is often used. Different methods are available to do this, usually based on a child's age or length. The accuracy of these methods has not been validated in Aboriginal and Torres Strait Islander children from remote communities. The objective of this study was to determine how well these paediatric emergency weight estimation methods predict weight for this group of children. A retrospective descriptive study using the measured weights and heights of Aboriginal and Torres Strait Islander children from remote locations across the Northern Territory (NT) was used. The weight estimation methods chosen to evaluate were the APLS, 'Best Guess', Luscombe and Nelson's formulae, Argall's modification, the Broselow® and Sandell® tapes, and the World Health Organization standard reference growth charts. Adjusted R-squared values for each method are reported, and agreement was measured in terms of mean percentage error (MPE). A total of 2102 children were included. The length-based methods performed the best. The Broselow Tape had the highest adjusted R-squared value at 0.8886 in all age groups. The APLS, Luscombe and Argall's methods were the worst performing methods. The Broselow® Tape was also the best performing in terms of accuracy and precision, with an MPE of -0.35% (95% CI -0.82-0.1). Our data support the use of the Broselow® Tape as the recommended method when estimating weight in an emergency for remote Aboriginal and Torres Strait Islander children in the NT for the 0-5 year age group.

BACKGROUND: Scabies causes considerable morbidity in disadvantaged populations. The International Alliance for the Control of Scabies (IACS) published consensus criteria in 2020 to standardize scabies diagnosis. However, these criteria are complex, and a WHO informal consultation proposed simplified criteria for mapping, to identify regions of high prevalence as targets for mass drug administration. We aimed to investigate the accuracy of simplified criteria in determining scabies prevalence, compared to the 2020 IACS criteria. METHODS: We obtained data relating to demographics, relevant history and skin lesions from all-age prevalence surveys from Fiji (n = 3365) and Solomon Islands (n = 5239), as well as school-aged children in Timor-Leste (n = 1043). We calculated prevalence using the 2020 IACS criteria and simplified criteria and compared these disease estimates. RESULTS: There was no significant difference in the pooled prevalence using the two methods (2020 IACS criteria: 16.6%; simplified criteria: 15.6%; difference = 0.9, [95% CI -0.1, 2.0]). In Timor-Leste, the prevalence using simplified criteria was lower (26.5% vs 33.8%). Simplified criteria had a sensitivity of 82.3% (95% CI 80.2, 84.2) and specificity of 97.6% (95% CI 97.2, 97.9) compared to the 2020 IACS criteria. CONCLUSIONS: The scabies prevalence estimation using simplified criteria was similar to using the 2020 IACS criteria in high prevalence, tropical countries. The prevalence estimation was lower in the school-based survey in Timor-Leste. Mapping using simplified criteria may be a feasible and effective public health tool to identify priority regions for scabies control. Further work assessing use of simplified criteria for mapping in a field setting should be conducted.

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Climate change threatens the health of all Australians: without adaptation, many areas may become unlivable, in particular the tropical north. The Northern Territory (NT) health workforce is already under colliding operational pressures worsened by extreme weather events, regional staff shortages and infrastructure that is poorly adapted to climate change. The H3 Project (Healthy Patients, Workforce and Environment) explores nature-based interventions in the NT health sector aiming to strengthen the resilience and responsiveness of health infrastructure and workforce in our climate-altered future. The H3 Project engaged the health workforce, climate researchers and the wider community, in recognition that meaningful and timely climate action requires both organization-led and grassroots engagement. We recruited campus greening volunteers and sustainability champions to Royal Darwin Hospital (RDH) to develop strategies that enhance climate adaptation, build climate and health literacy, and incentivize active mobility. We implemented low-cost biophilic design within the constraints of legacy healthcare infrastructure, creating cool and restorative outdoor spaces to mitigate the impacts of heat on RDH campus users and adapt to projected warming. This case study demonstrated substantial cooling impacts and improved local biodiversity and hospital campus aesthetics. We collaborated with Indigenous healers and plant experts to harness the synergy between Aboriginal people’s traditional knowledge and connectedness to land and the modern concept of biophilic design, while seeking to improve hospital outcomes for Indigenous patients who are both disconnected from their homelands and disproportionately represented in NT hospitals.

BACKGROUND: Acute febrile illnesses (AFIs), including dengue, scrub typhus and leptospirosis, cause significant morbidity and mortality in Southeast Asia. Serological surveillance can be used to investigate the force and distribution of infections. Dried blood spot (DBS) samples are an attractive alternative to serum because they are easier to collect and transport and require less cold storage. We conducted a pilot study to determine the feasibility of integrating serological surveillance for dengue, scrub typhus and leptospirosis into a population-representative lymphatic filariasis seroprevalence survey in Timor-Leste using DBSs. METHODS: A total of 272 DBSs were collected from healthy community participants. DBSs were analysed at the National Health Laboratory using commercially available enzyme-linked immunosorbent assays. To validate assays for DBSs, 20 anonymised serum samples of unknown serostatus were used to create dried serum spots (DSSs). These were analysed with optical densities compared with those of serum. Where low variance was observed (dengue assay) the published kit cut-offs for serum were applied to the analysis of DBSs. For the other assays (scrub typhus and leptospirosis), index values (IVs) were calculated and cut-offs were determined to be at 2 standard deviations (SDs) above the mean. RESULTS: Of the 272 samples analysed, 19 (7.0% [95% confidence interval {CI} 4.3 to 10.7]) were positive for dengue immunoglobulin G (IgG), 11 (4.0% [95% CI 2.1 to 7.1]) were positive for scrub typhus IgG and 16 (5.9% [95% CI 3.4 to 9.4%]) were positive for leptospira IgG. CONCLUSIONS: While dengue seroprevalence was lower than in nearby countries, results represent the first evidence of scrub typhus and leptospirosis transmission in Timor-Leste. Integrated programmes of serological surveillance could greatly improve our understanding of infectious disease epidemiology in remote areas and would incur minimal additional fieldwork costs. However, when planning such studies, the choice of assays, their validation for DBSs and the laboratory infrastructure and technical expertise at the proposed location of analysis must be considered.

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Currently there are no pharmacokinetic (PK) data to guide antibiotic dosing in critically ill Australian Indigenous patients with severe sepsis. This study aimed to determine whether the population pharmacokinetics of meropenem were different between critically ill Australian Indigenous and critically ill Caucasian patients. Serial plasma and urine samples as well as clinical and demographic data were collected over two dosing intervals from critically ill Australian Indigenous patients. Plasma meropenem concentrations were assayed by validated chromatography. Concentration-time data were analysed with data from a previous PK study in critically ill Caucasian patients using Pmetrics. The population PK model was subsequently used for Monte Carlo dosing simulations to describe optimal doses for these patients. Six Indigenous and five Caucasian subjects were included. A two-compartment model described the data adequately, with meropenem clearance and volume of distribution of the central compartment described by creatinine clearance (CLCr) and patient weight, respectively. Patient ethnicity was not supported as a covariate in the final model. Significant differences were observed for meropenem clearance between the Indigenous and Caucasian groups [median 11.0 (range 3.0-14.1) L/h vs. 17.4 (4.3-30.3) L/h, respectively; P <0.01]. Standard dosing regimens (1 g intravenous every 8 h as a 30-min infusion) consistently achieved target exposures at the minimum inhibitory concentration breakpoint in the absence of augmented renal clearance. No significant interethnic differences in meropenem pharmacokinetics between the Indigenous and Caucasian groups were detected and CLCr was found to be the strongest determinant of appropriate dosing regimens.

OBJECTIVE: Out-of-hospital cardiac arrest is an event with an extremely poor prognosis. There is limited literature on the outcomes for regional Australia, with none specifically addressing remote populations. We aimed to assess out-of-hospital cardiac arrest outcomes in the aeromedical retrieval population of the Top End Medical Retrieval Service. DESIGN: We retrospectively identified all cardiac arrests, deaths and patients who had cardiopulmonary resuscitation within the aeromedical retrieval database for a 5-year period from January 2012 to December 2016. SETTING: Retrieval patients across the Top End of the Northern Territory, Australia. PARTICIPANTS: All patients within the cohort with a non-traumatic out-of-hospital cardiac arrest. MAIN OUTCOME MEASURES: Data were collected on outcomes as per Utstein definitions, along with patient demographics, retrieval timings and interventions. RESULTS: Seventy-five patients suffering cardiac arrest were identified, with 58 having a non-traumatic arrest in an out-of-hospital setting. The median age of the cohort was 40 years, and 53% had an initial shockable rhythm. Return of spontaneous circulation was achieved in 55% and 43% survived to hospital. The survival to hospital discharge and 28 days were 31% and 29%, respectively. CONCLUSIONS: Although the study has a small sample size and limitations on generalisability due to the restricted nature of the cohort selection, the results suggest a 28-day survival rate is potentially comparable to other regions of Australia and the rest of the world. Further research needs to be undertaken in out-of-hospital cardiac arrest in remote regions to establish a true population-based cohort and ascertain where improvements can be made.

There are no available pharmacokinetic data to guide piperacillin dosing in critically ill Australian Indigenous patients despite numerous reported physiological differences. This study aimed to describe the population pharmacokinetics of piperacillin in critically ill Australian Indigenous patients with severe sepsis. A population pharmacokinetic study of Indigenous patients with severe sepsis was conducted in a remote hospital intensive care unit. Plasma samples were collected over two dosing intervals and assayed by validated chromatography. Population pharmacokinetic modeling was conducted using Pmetrics. Nine patients were recruited, and a two-compartment model adequately described the data. The piperacillin clearance (CL), volume of distribution of the central compartment (Vc), and distribution rate constants from the central to the peripheral compartment and from the peripheral to the central compartment were 5.6 ± 3.2 liters/h, 14.5 ± 6.6 liters, 1.5 ± 0.4 h-1, and 1.8 ± 0.9 h-1, respectively, where CL and Vc were found to be described by creatinine clearance (CLCR) and total body weight, respectively. In this patient population, piperacillin demonstrated high interindividual pharmacokinetic variability. CLCR was found to be the most important determinant of piperacillin pharmacokinetics.

Rarely, appendiceal neuroendocrine tumours (NET) are an incidental finding when an appendicectomy is undertaken for suspected appendicitis. The role of further imaging in this setting is poorly defined. Positron emission tomography (PET) using Ga-DOTATATE is requested to evaluate post-surgical status, however, there is little evidence to guide how it should be employed. The aims of this project are to: (i) characterize Ga-DOTATATE PET findings in patients with incidental appendiceal NETs and (ii) discuss how these data might inform post-surgical imaging with PET.We reviewed 47 PET scans in 30 patients, undertaken from 2009 to 2018. Scintigraphic findings, histopathological characteristics of the initial appendiceal lesion and medical records were reviewed.Most patients (n = 15) had small (<10 mm) appendiceal NETs with low grade (Ki67 < 2%) features. Eight patients had tumours between 10 and 20 mm, and seven had tumours >20 mm. Goblet cell features were identified in two patients. Three positive PET scans were reported in one patient with an index tumour measuring 40 mm and Ki67 < 2%. The remaining 29 patients had 44 negative scans. Clinical outcome data were available in 27 patients (mean follow-up time 57 months; range 6-123 months). There was no evidence of recurrent neuroendocrine disease at the time of the last follow-up.These data indicate that in most cases, post-surgical Ga-DOTATATE PET is negative in patients with incidentally detected appendiceal NETs. Clinical outcome data suggest that Ga-DOTATATE PET should be reserved for patients with large tumours (>20 mm) or those displaying goblet cell features.

Augmented renal clearance (ARC) refers to the enhanced renal excretion of circulating solute commonly demonstrated in numerous critically ill subgroups. This study aimed to describe the prevalence of ARC in critically ill Indigenous Australian patients and explore the accuracy of commonly employed mathematical estimates of glomerular filtration. We completed a single-centre, prospective, observational study in the intensive care unit (ICU), Alice Springs Hospital, Central Australia. Participants were critically ill adult Indigenous and non-Indigenous Australian patients with a urinary catheter in situ. Exclusion criteria were anuria, pregnancy or the requirement for renal replacement therapy. Daily eight-hour measured creatinine clearances (CrCL_m) were collected throughout the ICU stay. ARC was defined by a CrCL_m ≥130 ml/min/1.73 m². The Cockcroft-Gault and Chronic Kidney Disease Epidemiology Collaboration equations were also used to calculate mathematical estimates for comparison. In total, 131 patients were recruited (97 Indigenous, 34 non-Indigenous) and 445 samples were collected. The median (range) CrCL_m was 93.0 (5.14 to 205.2) and 90.4 (18.7 to 206.8) ml/min/1.73 m² in Indigenous and non-Indigenous patients, respectively. Thirty-one of 97 (32%) Indigenous patients manifested ARC, compared to 7 of 34 (21%) non-Indigenous patients (P=0.21). Younger age, major surgery, higher baseline renal function and an absence of diabetes were all associated with ARC. Both mathematical estimates manifest limited accuracy. ARC was prevalent in critically ill Indigenous patients, which places them at significant risk of underdosing with renally excreted drugs. CrCL_m should be obtained wherever possible to ensure accurate dosing.

BACKGROUND: Scabies and impetigo are endemic in many tropical, low- and middle-income countries. Mass drug administration (MDA) with ivermectin has emerged as a control strategy for these conditions. In 2019, Timor-Leste Ministry of Health planned to implement MDA including ivermectin for the control of lymphatic filariasis, so we undertook a baseline assessment of scabies and impetigo to better understand local epidemiology and contribute to future surveys assessing the impact of MDA. METHODS: A cross-sectional school survey was conducted in April-May 2019 at six primary schools in a semi-urban (Dili) and two rural (Ermera and Manufahi) settings. Children under 19 years of age present at school on survey days were eligible to participate, of whom we enrolled 1183. Trained health workers interviewed and examined 1043 participants to clinically diagnose scabies using the 2020 International Alliance for the Control of Scabies (IACS) diagnostic criteria, as well as impetigo. Prevalence was adjusted for age and sex. Mixed-effects logistic regression models were used to analyse odds of scabies and impetigo infection. All models accounted for clustering at the school level through the use of random effect terms. Population attributable risk of scabies as a cause of impetigo was also estimated. RESULTS: The overall weighted prevalence of scabies was 30.6%. Children in rural Manufahi were more likely to have scabies than those in semi-urban Dili (53.6% vs 28.2%, adjusted odds ratio [AOR] 3.5). Most cases of scabies were mild (3 to 10 lesions), and lesions were usually distributed on more than one body region. Scabies prevalence was lower among 10 to 14 year olds compared to 5 to 9 year olds. Overall weighted prevalence of impetigo was 11.3%. Relative to Dili, children in rural Ermera and Manufahi were twice as likely to have impetigo. Impetigo was twice as common in children with scabies than in those without, corresponding to an attributable risk of scabies as a cause of impetigo of 22.7%. CONCLUSIONS: Scabies and impetigo prevalence in Timor-Leste is among the highest reported globally, particularly in rural areas. Scabies infestation was strongly associated with impetigo. Comprehensive control strategies are urgently needed in Timor-Leste.