The genus Acinetobacter, well known as a nosocomial pathogen, can also cause severe community-onset pneumonia. Previous small case series have suggested fulminant disease and a pooled hospital mortality of > 60%. We conducted a prospective observational study of all episodes of bacteremic, community-onset, and radiologically confirmed pneumonia due to Acinetobacter species at a tertiary referral hospital in tropical Australia from 1997 to 2012 following the introduction of routine empirical treatment protocols covering Acinetobacter. Demographic, clinical, microbiologic, and outcome data were collected. There were 41 episodes of bacteremic community-onset Acinetobacter pneumonia, of which 36 had no indicators suggesting health-care-associated infection. Of these, 38 (93%) were Indigenous Australians, one-half were men, the average age was 44.1 years, and 36 episodes (88%) occurred during the rainy season. All patients had at least one risk factor, with hazardous alcohol intake in 82%. Of the 37 isolates available for molecular speciation, 35 were Acinetobacter baumannii and two were Acinetobacter nosocomialis. All isolates were susceptible in vitro to gentamicin, meropenem, and ciprofloxacin, but only one was fully susceptible to ceftriaxone. ICU admission was required in 80%. All 41 patients received appropriate antibiotics within the first 24 h of admission, and 28- and 90-day mortality were both low at 11%. Community-acquired Acinetobacter pneumonia is a severe disease, with the majority of patients requiring ICU admission. Most patients have risk factors, particularly hazardous alcohol use. Despite this severity, correct initial empirical antibiotic therapy in all patients was associated with low mortality.

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.

From November 1990 to June 1991 33 acute cases of melioidosis occurred in the Northern Territory, Australia; 25 cases were reported in the capital city, Darwin. We carried out an epidemiological investigation to exclude a common source outbreak, describe the risk factors for disease, and develop and institute appropriate control measures. We compared population based attack rates among various risk groups using logistic regression, and the demographic, medical and behavioral risk factors for melioidosis by a matched case-control study. Environmental Health Officers collected soil, surface water and cooling tower water specimens for Pseudomonas pseudomallei culture. The crude attack rate of melioidosis during the outbreak was 52 per 100,000. Age, gender, race, diabetes and alcohol abuse were independent risk factors for disease. The relative risk of disease in diabetic patients was 12.9 (95% CI 5.1-32.7; p < 0.001) and 6.7 in alcoholic patients (95% CI 2.9-15.2; p < 0.001). We found no significant difference between cases and controls in matched pair analysis for any of several exposure factors studied. We isolated Pseudomonas pseudomallei from 4% of soil samples and 9% of surface water samples. Our study confirms the importance of host factors in the development of melioidosis, and attempts to quantify the risk of disease during the Darwin epidemic. Pseudomonas pseudomallei is widespread in the soil of urban Darwin.

Cancer is one of the leading causes of death for Aboriginal and Torres Strait Islander people in the Northern Territory (NT). Accessible and culturally appropriate cancer screening programs are a vital component in reducing the burden of cancer. Primary health care plays a pivotal role in facilitating the uptake of cancer screening in the NT, due to the significant challenges caused by large distances, limited resources, and cultural differences. This paper analyses health care provider perspectives and approaches to the provision of cancer screening to Aboriginal people in the NT that were collected as part of a larger study. Semi-structured interviews were conducted with 50 staff from 15 health services, including 8 regional, remote, and very remote primary health care (PHC) clinics, 3 hospitals, a cancer centre, and 3 cancer support services. Transcripts were thematically analysed. Cancer screening by remote and very remote PHC clinics in the NT is variable, with some staff seeing cancer screening as a "huge gap", while others see it as lower priority compared to other conditions due to a lack of resourcing and the overwhelming burden of acute and chronic disease. Conversely, some clinics see screening as an area where they are performing well, with systematic screening, targeted programs, and high screening rates. There was a large variation in perceptions of the breast screening and cervical screening programs. However, participants universally reported that the bowel screening kit was complicated and not culturally appropriate for their Aboriginal patients, which led to low uptake. System-level improvements are required, including increased funding and resourcing for screening programs, and for PHC clinics in the NT. Being appropriately resourced would assist PHC clinics to incorporate a greater emphasis on cancer screening into adult health checks and would support PHCs to work with local communities to co-design targeted cancer screening programs and culturally relevant education activities. Addressing these issues are vital for NT PHC clinics to address the existing cancer screening gaps and achieving the Australian Government pledge to be the first nation in the world to eliminate cervical cancer as a public health problem by 2035. The implementation of the National Lung Cancer Screening Program in 2025 also presents an opportunity to deliver greater benefits to Aboriginal communities and reduce the cancer burden.

In low-to-middle-income countries (LMICs), enteric pathogens contribute to child malnutrition, affecting nutrient absorption, inducing inflammation, and causing diarrhoea. This is a substantial problem in LMICs due to high disease burden, poor sanitation and nutritional status, and the cyclical nature of pathogen infection and malnutrition. This relationship remains understudied in Timor-Leste. In our pilot study of enteric pathogens and malnutrition in Dili, Timor-Leste (July 2019-October 2020), we recruited 60 infants in a birth cohort from Hospital Nacional Guido Valadares (HNGV) with up to four home visits. We collected faecal samples and details of demographics, anthropometrics, diet and food practices, and animal husbandry. Additionally, we collected faecal samples, diagnostics, and anthropometrics from 160 children admitted to HNGV with a clinical diagnosis of severe diarrhoea or severe acute malnutrition (SAM). We tested faeces using the BioFire® FilmArray® Gastrointestinal Panel. We detected high prevalence of enteric pathogens in 68.8% (95%CI 60.4-76.2%) of infants at home, 88.6% of SAM cases (95%CI 81.7-93.3%) and 93.8% of severe diarrhoea cases (95%CI 67.7-99.7%). Diarrhoeagenic Escherichia coli and Campylobacter spp. were most frequently detected. Pathogen presence did not significantly differ in birth cohort diarrhoeal stool, but hospital data indicated associations between Salmonella and Shigella and diarrhoea. We observed wasting in 18.4% (95%CI 9.2-32.5%) to 30.8% (95%CI 17.5-47.7%) of infants across home visits, 57.9% (95%CI 34.0-78.9%) of severe diarrhoea cases, and 92.5% (95%CI 86.4-96.2%) of SAM cases. We associated bottle feeding with increased odds of pathogen detection when compared with exclusive breastfeeding at home (OR 8.3, 95%CI 1.1-62.7). We detected high prevalence of enteric pathogens and signs of malnutrition in children in Dili. Our pilot is proof of concept for a study to fully explore the risk factors and associations between enteric pathogens and malnutrition in Timor-Leste.

BACKGROUND: Preterm birth (PTB) is the single most important cause of perinatal mortality and morbidity in high income countries. In Australia, 8.6% of babies are born preterm but substantial variability exists between States and Territories. Previous reports suggest PTB rates are highest in the Northern Territory (NT), but comprehensive analysis of trends and risk factors are lacking in this region. The objective of this study was to characterise temporal trends in PTB among First Nations and non-First Nations mothers in the Top End of the NT over a 10-year period and to identify perinatal factors associated with the risk of PTB. METHODS: This was a retrospective population-based cohort study of all births in the Top End of the NT over the 10-year period from January 1st, 2008, to December 31st, 2017. We described maternal characteristics, obstetric complications, birth characteristics and annual trends in PTB. The association between the characteristics and the risk of PTB was determined using univariate and multivariate generalised linear models producing crude risk ratios (cRR) and adjusted risk ratios (aRR). Data were analysed overall, in First Nations and non-First Nations women. RESULTS: During the decade ending in 2017, annual rates of PTB in the Top End of the NT remained consistently close to 10% of all live births. However, First Nations women experienced more than twice the risk of PTB (16%) compared to other women (7%). Leading risk factors for PTB among First Nations women as compared to other women included premature rupture of membranes (RR 12.33; 95% CI 11.78, 12.90), multiple pregnancy (RR 7.24; 95% CI 6.68, 7.83), antepartum haemorrhage (RR 4.36; 95% CI 3.93, 4.84) and pre-existing diabetes (RR 4.18; 95% CI 3.67, 4.76). CONCLUSIONS: First Nations women experience some of the highest PTB rates globally. Addressing specific pregnancy complications provides avenues for intervention, but the story is complex and deeper exploration is warranted. A holistic approach that also acknowledges the influence of socio-demographic influences, such as remote dwelling and disadvantage on disease burden, will be required to improve perinatal outcomes.

Objectives: Crusted scabies (CS, Norwegian scabies) is a severe form of scabies, characterized by hyper-infestation of Sarcoptes scabiei mites. CS is commonly associated with immunosuppression but is also reported in overtly immunocompetent individuals. We reviewed immunosuppressive risk factors and comorbidities associated with CS. Methods: The National Library of Medicine (PubMed) database was reviewed for patient case reports of CS from January 1998 to July 2023. Two authors screened records for eligibility, extracted data, and one critically appraised the quality of the studies. Systematic review registration: PROSPERO CRD42023466126. Results: A total of 436 records were identified, of which 204 were included for systematic review. From these, 683 CS patients were included. CS impacted both genders equally. Adults (21-59 years) were more commonly affected (45.5%) compared to children (0-20 years, 21%). Corticosteroid use was the most prevalent immunosuppressive risk factor identified (27.7% of all cases). About 10.2% of reports were associated with HIV/AIDS, and 8.5% with HTLV-1 infection. 10.5% of patients were overtly immunocompetent with no known risk factors. Overall, 41 (6.0%) died, many subsequent to secondary bacteremia. Conclusion: This study represents the first systematic review undertaken on immunosuppressive risk factors associated with CS. This provides insights into trends of immunosuppression and mechanisms of CS development.

To compare perinatal deaths in Aborigines and non-Aborigines, and to identify the differences between the two groups in order to plan better prevention and bring about a reduction in perinatal deaths. A retrospective review of the records of 198 consecutive perinatal deaths (96 Aboriginal and 102 non-Aboriginal) in infants delivered in the maternity unit between 1984 and 1989. Royal Darwin Hospital Maternity Unit. Stillbirth rate, neonatal death rate, perinatal mortality rate; classifying perinatal deaths by cause and birthweight. The Aboriginal perinatal mortality rate was 40.9 per 1000, three times that of the non-Aboriginal rate (13.4 per 1000). The stillbirth rate in Aborigines was 18.7 per 1000, 2.5 times that in non-Aborigines (7.2 per 1000). The Aboriginal neonatal mortality rate was 22.5 per 1000, 3.5 times the non-Aboriginal rate (6.2 per 1000). There was no significant difference in the distribution of Aboriginal and non-Aboriginal perinatal deaths when classified by cause, with the exception of pre-eclampsia. Aboriginal women appeared to be 2.5 times more likely than non-Aboriginal women (P = 0.002) to have pre-eclampsia causing perinatal death. Prematurity and the unexplained categories were the major causes of perinatal death in both Aboriginal and non-Aboriginal infants. The suboptimal perinatal outcome in Aborigines highlights the importance of antenatal care for Aboriginal mothers, and indirectly reflects the need for improving their standard of living.

With increasing implementation of casemix-based funding for hospitals, quantitative data were needed to confirm the clinical impression that treating Aboriginal (compared with non-Aboriginal) inpatients consumes significantly more resources. Utilisation data, collected over a three-month period in 10 hospitals, were used to determine a cost per inpatient episode, which was grouped according to AN-DRG-3 to give a cost per AN-DRG for Aboriginal and Torres Strait Islander (ATSI) patients and non-ATSI patients. ATSI patients had consistently longer average length of stay and significant variation in relative frequency of admissions, compared with non-ATSI patients, with higher prevalences of infectious diseases. Degenerative and neoplastic conditions were more common in non-ATSI patients. There were significant differences in casemix-adjusted costs per patient episode (ATSI, $1856; non-ATSI, $1558; P < 0.001). Our study has quantified differential resource consumption between two Australian populations, and highlights the need for recognition of some hospitals' atypical populations and special funding requirements.

This article reviews the changing Aboriginal mental health service delivery model of Top End Mental Health Services, and highlights the importance of Aboriginal mental health workers in improving communication with Aboriginal patients. The Australian Integrated Mental Health Initiative Northern Territory Indigenous stream (AIMHI NT) is introduced. Baseline measures of AIMHI NT in 2003, and findings from two clinical file audits (1996 and 2001) at Royal Darwin Hospital inpatient unit are presented. The files were audited for a range of assessment and treatment interventions. The audits reveal significant improvements in Aboriginal inpatient care between 1995 and 2001. Aboriginal mental health workers provide essential services as cross-cultural brokers in the setting of Aboriginal mental illness. The improvements in care found in this file audit coincide with the commencement of employment of Aboriginal mental health workers in the inpatient unit. The AIMHI consultation reveals broad support for employment of more Aboriginal mental health workers in the Top End.

Aboriginal and Torres Strait Islander Australians experience high rates of mental illness and psychological distress compared to their non-Indigenous counterparts. E-mental health tools offer an opportunity for accessible, effective, and acceptable treatment. The AIMhi Stay Strong app and the ibobbly suicide prevention app are treatment tools designed to combat the disproportionately high levels of mental illness and stress experienced within the Aboriginal and Torres Strait Islander community. This study aimed to explore Aboriginal and Torres Strait Islander community members' experiences of using two culturally responsive e-mental health apps and identify factors that influence the acceptability of these approaches. Using qualitative methods aligned with a phenomenological approach, we explored the acceptability of two culturally responsive e-mental health apps through a series of three 3-hour focus groups with nine Aboriginal and Torres Strait Islander community members. Thematic analysis was conducted and coresearcher and member checking were used to verify findings. Findings suggest strong support for the concept of e-mental health apps and optimism for their potential. Factors that influenced acceptability related to three key themes: personal factors (eg, motivation, severity and awareness of illness, technological competence, and literacy and language differences), environmental factors (eg, community awareness, stigma, and availability of support), and app characteristics (eg, ease of use, content, graphics, access, and security and information sharing). Specific adaptations, such as local production, culturally relevant content and graphics, a purposeful journey, clear navigation, meaningful language, options to assist people with language differences, offline use, and password protection may aid uptake. When designed to meet the needs of Aboriginal and Torres Strait Islander Australians, e-mental health tools add an important element to public health approaches for improving the well-being of Aboriginal and Torres Strait Islander people.

We describe a haemodialysis patient who presented with an exacerbation of previously undiagnosed chronic focal myositis during a hospital admission for missed dialysis and chronic foot osteomyelitis. The association of focal myositis with haemodialysis has been reported once previously, but we report the third case in our experience and argue that it is probably more common than previously appreciated. We consider a focused differential diagnosis for a diabetic dialysis patient with leg pain and discuss important features of this rare condition.

The apparent incidence of acute hepatitis B infection in the Top End of the Northern Territory was estimated from notification data and hospital data to be 12 per 100,000 per year, with a marked difference between Aborigines (42 per 100,000) and non-Aborigines (4 per 100,000), and an odds ratio of 9.7 (95 per cent confidence intervals 3 to 33). Sixty percent of Aboriginal cases of acute hepatitis B occurred in children under 10 years of age, whereas non-Aboriginal cases occurred in adults aged 20 to 29, most with behavioural risk factors. These findings confirm the importance of immunising Aboriginal children to reduce the future incidence of hepatitis B infection and hepatoma.

OBJECTIVE: To describe the epidemiological and clinical features of acute rheumatic fever and rheumatic heart disease in the Top End of the Northern Territory. METHODS: A retrospective review (in some instances as far back as the 1960s) of all cases of known or suspected acute rheumatic fever or rheumatic heart diseases, with prospective validation of clinical status where necessary. Cases were ascertained from hospital and community medical clinic records and medical staff; and from records and health staff of 10 rural communities. RESULTS: Three hundred and eighty-six revised Jones criteria-confirmed episodes of acute rheumatic fever were documented in 249 individuals (99% Aboriginal). The annual incidence of confirmed acute rheumatic fever between 1989 and 1993 was 254 per 100,000 Aboriginal people aged 5 to 14 years. A more accurate estimate of 651 per 100,000 came from 10 rural communities with more complete information. As of 1995, there were 286 people living with established rheumatic heart disease (95% Aboriginal). The point prevalence of rheumatic heart disease among Aboriginal people was 9.6 per 1000, with a rate of 24 per 1000 in one large rural community. Sydenham's chorea was common, and associated with later rheumatic heart disease in 49% of cases. There was a preponderance of females with acute rheumatic fever, rheumatic heart disease and chorea. CONCLUSIONS: In Aboriginal people in rural northern Australia the incidence of acute rheumatic fever is higher than that reported anywhere in the world, and the prevalence of rheumatic heart disease is among the highest in the world. While continuing attention must be paid to alleviating the causes of these diseases of poverty, immediate action is needed to improve diagnosis of acute rheumatic fever, adherence to secondary benzathine penicillin prophylaxis regimens, and follow-up of rheumatic heart disease cases.

This paper evaluates adherence with secondary preventative treatment and follow up of acute rheumatic fever (ARF) within the Katherine region of the Northern Territory after the introduction of an ARF register. We aimed to assess the rate of adherence with penicillin prophylaxis and follow-up guidelines in patients with previous ARF and the effect of factors such as age, sex, disease severity and clinic attendance. Retrospective study. Five Indigenous Community Health Centres located in the Katherine region of the Northern Territory, Australia. Fifty-nine people resident in five communities who were prescribed monthly prophylactic penicillin for ARF during the 24 months between September 2002 and September 2004. All subjects were Indigenous. Main outcome measures were the number of penicillin injections received over the 24-month period and frequency of echocardiogram and specialist follow up in comparison to Rheumatic Fever Registry Guidelines. Mean adherence with prophylaxis was 56% of prescribed doses. A non-significant trend towards improved adherence was seen in children, patients with less severe disease and those who attended the clinic more frequently. Rheumatic Fever Registry Guidelines for echocardiogram and specialist review were met by 63% and 59% of subjects, respectively. Within this population adherence with penicillin prophylaxis is inadequate to protect against recurrence of ARF and consequent worsening of rheumatic heart disease. In addition, the Rheumatic Fever Registry Guidelines for specialist follow up and echocardiogram are not being adhered to for many patients.

A key challenge to providing quality developmental care in remote Aboriginal primary health care (PHC) centers has been the absence of culturally appropriate developmental screening instruments. This study focused on the cross-cultural adaptation of the Ages and Stages Questionnaires, 3rd edition (ASQ-3), with careful attention to language and culture. We aimed to adapt the ASQ-3 for use with remote dwelling Australian Aboriginal children, and to investigate the cultural appropriateness and feasibility of the adapted ASQ-3 for use in this context. We undertook a qualitative study in two remote Australian Aboriginal communities, using a six-step collaborative adaptation process. Aboriginal Health Workers (AHWs) were trained to use the adapted ASQ-3, and follow-up interviews examined participants' views of the cultural acceptability and usefulness of the adapted instrument. The adapted ASQ-3 was found to have high face validity and to be culturally acceptable and relevant to parents, AHWs, and early childhood development experts.

No abstract available

In high-burden Australian states and territories, registers of patients with acute rheumatic fever and rheumatic heart disease are maintained for patient management, monitoring of system performance and research. Data validation was undertaken for the Australian Northern Territory Rheumatic Heart Disease Register to determine quality and impact of data cleaning on reporting against key performance indicators: overall adherence, and proportion of patients receiving ≥80% of scheduled penicillin doses for secondary prophylaxis. Register data were compared with data from health centres. Inconsistencies were identified and corrected; adherence was calculated before and after cleaning. 2780 penicillin doses were validated; 426 inconsistencies were identified, including 102 incorrect dose dates. After cleaning, mean adherence increased (63.5% to 67.3%, p<0.001) and proportion of patients receiving ≥80% of doses increased (34.2% to 42.1%, p = 0.06). The Northern Territory Rheumatic Heart Disease Register underestimates adherence, although the key performance indicator of ≥80% adherence was not significantly affected. Program performance is better than hitherto appreciated. However some errors could affect patient management, as well as accuracy of longitudinal or inter-jurisdictional comparisons. Adequate resources are needed for maintenance of data quality in acute rheumatic fever/rheumatic heart disease registers to ensure provision of evidence-based care and accurate assessment of program impact.

Melioidosis, caused by the intracellular pathogen Burkholderia pseudomallei, is endemic in northern Australia and Southeast Asia. Risk factors for this infection have also been associated with functional neutrophil defects. Because of this, granulocyte colony-stimulating factor (G-CSF) was adopted for use in patients with septic shock due to melioidosis in December 1998. We compared the mortality rates from before and after the introduction of G-CSF therapy at the Royal Darwin Hospital (Darwin, Australia) during the period of 1989-2002. The mortality rate decreased from 95% to 10% after the introduction of G-CSF. Risk factors, the duration of illness before presentation, and the severity of illness were similar in both groups. A smaller decrease in mortality among patients in the intensive care unit who did not have melioidosis was observed, suggesting that other changes in management did not account for the magnitude of the benefit seen. We conclude that G-CSF may have contributed to the reduction in the mortality rate among patients with septic shock due to melioidosis.