This study investigates the burden of cardiovascular risk markers in people with and without diabetes in a remote Indigenous Australian community, based on their HbA1c concentration. This study included health screening exams of 1187 remote Indigenous residents over 15 years old who represented 70% of the age-eligible community. The participants were stratified by HbA1c into 5 groups using cut-off points recommended by international organisations. The associations of traditional cardiovascular risk markers with HbA1c groups were assessed using logistic and linear regressions and ANOVA models. Of the 1187 participants, 158 (13%) had a previous diabetes diagnosis, up to 568 (48%) were at high risk (5.7-6.4% (39-46 mmol/mol) HbA1c), and 67 (6%) potential new cases of diabetes (≥6.5% (48 mmol/mol)) were identified. Individuals with higher HbA1c levels were more likely to have albuminuria (OR 3.14, 95% CI 1.26-7.82) and dyslipidaemia (OR 2.37, 95% CI 1.29-4.34) and visited the clinic more often (OR 2.52, 95% CI 1.26-4.99). Almost all traditional CVD risk factors showed a positive association with HbA1c. Screening in this remote Indigenous Australian community highlights the high proportion of individuals who are at high risk of diabetes as indicated by HbA1c and who also had an accentuated cardiovascular risk profile.

The aim of this study was to determine if any disaster triage tag is superior to others, based on objective parameters (time, accuracy) and subjective parameters (user preference). A secondary aim was to determine the average time to perform triage assessment using 'sieve and sort'. This was a prospective, randomised cross-over trial comparing triage cards currently used, or being implemented, across Australia. De-identified patient information from a trauma database was used to create 125 cases. Volunteer participants were selected from Major Incident Medical Management and Support certified doctors, nurses, paramedics and defence medics and randomised into five groups. Participants completed timed 'sieve and sort' triage exercises on 25 different cases with each of the five triage tags and were then asked to rank the tags in order of preference. Participants also performed timed practical triage assessments (sieve and sort) on two healthy volunteers. Based on the objective measures we did not find that one card was superior to others; however, the Northern Territory card was significantly slower and less accurate (P < 0.001). Doctors were the fastest and most accurate 'sorters' (P < 0.001); however, inaccuracy was the same for all professional groups for the 'sieve'. Participants preferred the SMART card to any other tag. Participants' time to carry out a sieve was approximately 30 s, and 60 s for a sort. The SMART card was preferred by participants based on design issues, which supports its implementation. We suggest that doctors are best used in the casualty clearing post.

Plasmodium knowlesi causes severe and fatal malaria in Malaysia. Microscopic misdiagnosis is common and may delay appropriate treatment. P. knowlesi can cross-react with "species-specific" parasite lactate dehydrogenase (pLDH) monoclonal antibodies used in rapid diagnostic tests (RDTs) to detect P. falciparum and P. vivax. At one tertiary-care hospital and two district hospitals in Sabah, we prospectively evaluated two combination RDTs for malaria diagnosis by using both a pan-Plasmodium-pLDH (pan-pLDH)/P. falciparum-specific-pLDH (Pf-pLDH) RDT (OptiMAL-IT) and a non-P. falciparum VOM-pLDH/Pf-HRP2 RDT (CareStart). Differential cross-reactivity among these combinations was hypothesized to differentiate P. knowlesi from other Plasmodium monoinfections. Among 323 patients with PCR-confirmed P. knowlesi (n = 193), P. falciparum (n = 93), and P. vivax (n = 37) monoinfections, the VOM-pLDH individual component had the highest sensitivity for nonsevere (35%; 95% confidence interval [CI], 27 to 43%) and severe (92%; CI, 81 to 100%) P. knowlesi malaria. CareStart demonstrated a P. knowlesi sensitivity of 42% (CI, 34 to 49%) and specificity of 74% (CI, 65 to 82%), a P. vivax sensitivity of 83% (CI, 66 to 93%) and specificity of 71% (CI, 65 to 76%), and a P. falciparum sensitivity of 97% (CI, 90 to 99%) and specificity of 99% (CI, 97 to 100%). OptiMAL-IT demonstrated a P. knowlesi sensitivity of 32% (CI, 25 to 39%) and specificity of 21% (CI, 15 to 29%), a P. vivax sensitivity of 60% (CI, 42 to 75%) and specificity of 97% (CI, 94 to 99%), and a P. falciparum sensitivity of 82% (CI, 72 to 89%) and specificity of 39% (CI, 33 to 46%). The combination of CareStart plus OptiMAL-IT for P. knowlesi using predefined criteria gave a sensitivity of 25% (CI, 19 to 32%) and specificity of 97% (CI, 92 to 99%). Combining two RDT combinations was highly specific for P. knowlesi malaria diagnosis; however, sensitivity was poor. The specificity of pLDH RDTs was decreased for P. vivax and P. falciparum because of P. knowlesi cross-reactivity and cautions against their use alone in areas where P. knowlesi malaria is endemic. Sensitive P. knowlesi-specific RDTs and/or alternative molecular diagnostic tools are needed in areas where P. knowlesi malaria is endemic.

To examine the relationship between ethnicity and triage at a tertiary hospital emergency department. Electronic Emergency Department Information System data analysis was used to examine the relationship between ethnicity and triage allocation and process times between 1 April 1999 and 29 June 1999. Outcome measures were waiting times by triage category and admission rate by triage category. There were 9614 attendances: 1949 indigenous (20.3%), 7328 non-indigenous (76.2%) and 337 (3.5%) had no ethnicity recorded. Indigenous patients were more often female (1033; 53%, CI 51-55%) than non-indigenous patients (3078; 42.0%, CI 41-43%, P < 0.001). Indigenous patients presented more often with illness (70% CI 68-72%) rather than injury (30%, CI 28-32%), compared with the non-indigenous patients, illness (64%, CI 63-65%), injury (36%, CI 35-37%, P < 0.001). Indigenous patients were more likely to be triaged to national triage scale categories 1, 2 or 3 (36%, CI 34-38%) than non-indigenous patients (32%, CI 31-33%, P = 0.011). Admission rates for indigenous patients were higher than non-indigenous patients across all urgency categories and were within national triage scale guidelines. Non-indigenous admission rates were well below national triage scale guidelines for all urgency categories. The overall admission rate for indigenous patients was double (33%, CI 31-35%) that for non-indigenous patients (16%, CI 15-17%, P < 0.001). There was no significant difference between indigenous and non-indigenous waiting times. Indigenous patients are more likely to present with illness rather than injury and are more likely to require admission than non-indigenous patients. Indigenous patients are triaged in accordance with Australasian triage guidelines. Many non-indigenous patients should be triaged to lower urgency categories to allow resource allocation towards higher acuity indigenous and non-indigenous patients.

OBJECTIVE: To investigate the effectiveness of hot water immersion for relieving the pain of major box jellyfish (Chironex fleckeri) stings.Design, interventions: Open label, randomised controlled trial comparing the effects of hot water immersion (45°C) and icepacks.Setting, participants: 42 patients with suspected C. fleckeri stings treated in the emergency department of the Royal Darwin Hospital during September 2005 - October 2008. MAIN OUTCOME MEASURES: The primary outcome was pain severity, assessed with a visual analogue scale (VAS). Secondary outcomes included crossover to the alternative treatment, use of opioid analgesia, emergency department length of stay (LOS), and delayed urticaria. RESULTS: Of 42 patients (26 males; median age, 19 years; IQR, 13-27 years), 25 were allocated to icepack treatment and 17 to hot water immersion. The demographic and baseline VAS data for the two groups were similar. After 30 minutes of treatment, 11 patients (65%) treated with hot water and 14 (56%) treated with icepacks had clinically improved pain scores (absolute difference, 9%; 95% CI, -22% to 39%; P = 0.75). One patient treated with icepacks crossed over to heat immersion. Two patients in each arm received intravenous opioid analgesia. Median emergency department LOS was 1.6 h (IQR, 1.0-1.8 h) for icepack patients and 2.1 h (IQR, 1.6-2.8 h) for heat immersion patients (P = 0.07). Five of seven patients who were followed up developed delayed urticaria. CONCLUSION: Hot water immersion was no more effective than icepacks for reducing the acute pain of box jellyfish stings, but increased emergency department LOS by about 30 minutes. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12605000007639.

Decreased bioavailability of nitric oxide (NO) is a major contributor to the pathophysiology of severe falciparum malaria. Tetrahydrobiopterin (BH4) is an enzyme cofactor required for NO synthesis from L-arginine. We hypothesized that systemic levels of BH₄ would be decreased in children with cerebral malaria, contributing to low NO bioavailability. In an observational study in Tanzania, we measured urine levels of biopterin in its various redox states (fully reduced [BH₄] and the oxidized metabolites, dihydrobiopterin [BH₂] and biopterin [B₀]) in children with uncomplicated malaria (UM, n = 55), cerebral malaria (CM, n = 45), non-malaria central nervous system conditions (NMC, n = 48), and in 111 healthy controls (HC). Median urine BH4 concentration in CM (1.10 [IQR:0.55-2.18] μmol/mmol creatinine) was significantly lower compared to each of the other three groups - UM (2.10 [IQR:1.32-3.14];p<0.001), NMC (1.52 [IQR:1.01-2.71];p = 0.002), and HC (1.60 [IQR:1.15-2.23];p = 0.005). Oxidized biopterins were increased, and the BH4:BH2 ratio markedly decreased in CM. In a multivariate logistic regression model, each Log10-unit decrease in urine BH4 was independently associated with a 3.85-fold (95% CI:1.89-7.61) increase in odds of CM (p<0.001). Low systemic BH4 levels and increased oxidized biopterins contribute to the low NO bioavailability observed in CM. Adjunctive therapy to regenerate BH4 may have a role in improving NO bioavailability and microvascular perfusion in severe falciparum malaria.

To determine the hospitalization rates from asthma for Aboriginal and Torres Strait Islander (ATSI) and non-Aboriginal (non-ATSI) children in the 'top end' of the Northern Territory and to determine the proportion of hospitalizations due to asthma. A retrospective review was undertaken of separation data from the Royal Darwin Hospital for the period July 1991 to June 1997. All children aged 1-9 years residing in the Darwin urban or rural district were included, with asthma identified by the International Classification of Diseases Version 9 codes 493.0-493.9. The overall average annual hospitalization rate per 1000 population with a principal diagnosis of asthma for ATSI children from rural areas (ATSI-rural) was 2.6, 4.7 for ATSI children from urban areas (ATSI-urban) and 5.5 for non-ATSI children. These hospitalization rates were significantly different between ATSI and non-ATSI children (rate ratio 0.72, 95% CI 0.59-0.86). On stratification for residence, the rates were significantly different between ATSI-rural and non-ATSI children (rate ratio 0.61, 95% CI 0. 47-0.80) but not different between rural and urban dwelling ATSI children (rate ratio 0.76, 95% CI 0.54-1.07) or between ATSI-urban children and non-ATSI children (rate ratio 0.81, 95% CI 0.63-1.03). Asthma was diagnosed in 6.5% of ATSI admissions (4.0% for ATSI-rural and 13.8% for ATSI-urban) and 12.7% of non-ATSI admissions. The hospitalization rate for ATSI children with asthma was significantly lower than for non-ATSI children. Asthma plays a far less significant role in the spectrum of disease affecting hospitalized ATSI children compared to non-ATSI children. There are significant differences in disease frequency between urban and rural resident ATSI children but less marked differences between urban resident ATSI children and non-ATSI children. Further study is required if the underlying causes behind these differences are to be determined.

To compare three low-lactose milk formulas differing in osmolality and degree of protein hydrolysis in the treatment of diarrhoea and malnutrition in subjects with high rates of lactose intolerance, osmotic diarrhoea and a tropical/environmental enteropathy. A randomized double-blind trial of 180 Aboriginal children under 3 years of age admitted with acute diarrhoea and/or malnutrition was carried out. The intervention milk formulas were: (i) De-Lact, a low-osmolality lactose-free formula; (ii) O-Lac, a lactose-free formula; and (iii) Alfaré, a partially hydrolysed formula. Outcome measures were diarrhoeal severity, weight gain, formula palatability and changes in intestinal permeability (L/R ratios). The duration of diarrhoea in days (mean; 95% confidence interval) was significantly longer on Alfaré (8.5; 7.0-10.0) compared to De-Lact (6.1; 5.0-7.2) and O-Lac (6.9; 5.6-8.1; P = 0.04). There were no differences in mean intake between formulas, but palatability of Alfaré was significantly worse (P < 0.01) than the other formulas. Over the trial 5 days, improvement in L/R ratios was significantly greater (P = 0.05) for De-Lact (18.6; 10.6-26.6) than for Alfaré (8.5; 2.1-14.9). Weight gain was not significantly different between the three formulas, except in a malnourished subgroup who had better weight gain on De-Lact (P = 0.05). In these Aboriginal children with diarrhoea and growth failure, a low osmolality milk was associated with better outcomes and a partially hydrolysed formula with less improvement in mucosal recovery, suggesting that cow's milk protein intolerance is not contributing to greater diarrhoeal severity or enteropathy in Aboriginal children.

Occupational therapy in very remote, predominantly Indigenous, settings requires therapists to modify traditional models of practice to make practice applicable, culturally relevant and culturally safe. This article describes some of the author's observations of similarities and differences in what occupational therapy 'does' and 'is' in four different, but in many ways similar, very remote contexts. A Churchill Fellowship allowed the author to travel to visit teams in three very remote regions of Canada and the USA, allowing comparison to practice in the Top End of the Northern Territory in Australia. These very remote settings are unable to support onsite therapy services resulting in fly/drive-in visits from hub towns, influencing service models and extending professional tasks and roles. In many of these remote contexts populations are predominantly Indigenous, which requires therapists to work cross-culturally. This requires occupational therapists to adapt therapy assessments and interventions to make these appropriate to the contexts. Therapists perceived a range of therapeutic adaptations and resources as useful in their practice and some barriers to implementing these. These included supports to practice such as cultural liaisons or interpreters; being open and respectful to differences in beliefs around health, wellbeing, desired occupational pursuits and function; using a client/family-directed approach in care planning, goal setting and development of therapeutic strategies; being selective around use of standardised assessment tools; and taking time and developing relationships with family and clients. Therapists in these areas also reported their scope of practice as being broader in remote settings, requiring skills in a greater range of areas. Therapists also reported the increased use of technology to supplement and support remote practice.

It has been proposed that the Chronic Kidney Disease Epidemiology Collaboration formula estimates glomerular filtration rate more accurately than the Modification of Diet in Renal Disease formula. With the very high incidence of diabetes and end-stage kidney disease in Indigenous Australians, accurate estimation of glomerular filtration rate is vital in early detection of kidney disease. We aimed to assess the performance of the Chronic Kidney Disease Epidemiology Collaboration, Modification of Diet in Renal Disease and Cockcroft-Gault formulas in Indigenous Australians with and without diabetes. Indigenous Australians with (n = 224) or without (n = 340) Type 2 diabetes had a reference glomerular filtration rate measure using plasma disappearance of iohexol (measured glomerular filtration rate) over 4 h. Serum creatinine was measured by an enzymatic method. Performance was assessed by bias (measured glomerular filtration rate - estimated glomerular filtration rate) and accuracy (percentage of estimated glomerular filtration rate within 30% of measured glomerular filtration rate). The median measured glomerular filtration rate (interquartile range) in participants with or without diabetes was 97 (68-119) and 108 (90-122) ml min(-1)  1.73 m(-2) , respectively. The Chronic Kidney Disease Epidemiology Collaboration formula had smaller bias and greater accuracy than the Modification of Diet in Renal Disease and Cockcroft-Gault formulas overall, for participants both with and without diabetes. However, for estimated glomerular filtration rate > 90 ml min(-1)  1.73 m(-2) , the Chronic Kidney Disease Epidemiology Collaboration formula had greater bias in participants with diabetes, underestimating measured glomerular filtration rate by 7.4 vs. 1.0 ml min(-1)  1.73 m(-2) in those without diabetes. The Chronic Kidney Disease Epidemiology Collaboration formula was less accurate across the whole range of estimated glomerular filtration rates in participants with vs. those without diabetes (87.1% vs. 93.3%). The Chronic Kidney Disease Epidemiology Collaboration formula outperforms the Modification of Diet in Renal Disease and Cockcroft-Gault formulas overall in Indigenous Australians with and without diabetes. However, the Chronic Kidney Disease Epidemiology Collaboration formula has greater bias in people with diabetes compared with those without diabetes, especially in those with normal renal function.

The aim of the study was to assess the appropriateness of use of fresh-frozen plasma (FFP) at Royal Darwin Hospital against the National Health and Medical Research Council and Australian and New Zealand Society for Blood Transfusion guidelines. A retrospective review of blood product request forms, online pathology storage system data, pathology records and clinical notes between 1 January 2006 and 31 December 2006 was carried out. The appropriateness of requests was assessed against existing guidelines. The percentage of appropriate and inappropriate FFP transfusions was obtained. Six hundred and forty-eight of 950 units (68%) of FFP were used with an appropriate indication as per National Health and Medical Research Council/Australian and New Zealand Society for Blood Transfusion guidelines. Of the remaining units, 14% (137 units) was given without a clear indication and a decision of appropriateness could not be established for 17% (165 units) because of inadequate clinical or pathology information (e.g. coagulation results). Multiple issues around prescribing practice were identified. There is significant use of FFP at Royal Darwin Hospital without clear clinical indication. The employment of a transfusion nurse to monitor use of FFP (and other blood products) and provide education is aimed at improving transfusion efficiency and patient safety.

To assess the visual outcomes and quality of life after cataract surgery in Aborig nal people and compare them with a case-matched population of non-Aborginal people living in remote and rural areas in the Top End of the Northern Territory. Patients living in remote areas of the Top End of the Northern Territory who underwent cataract surgery between 1994 and 1999 were identified from records at the three major hospitals in the region. Eighty-three patients were included in the study. Each patient underwent a complete ocular assessment and then was administered a standardized, field-tested, 12-item questionnaire concerning visual function. This was analyzed and the results of the Aboriginal and matched non-Aboriginal populations compared. Sixty one Aboriginal and 22 non-Aboriginal people from a total of 295 patients who underwent cataract surgery were included in the study. The two study groups were closely matched by sex, age at the time of surgery, time of follow up from surgery and the number who had undergone bilateral surgeryThe median preoperative visual acuity for the Aboriginal group was 6/60 against 6/24 of the non-Aboriginal group. After surgery, at the time of follow up, 26% of eyes in Aboriginal patients did not correct to 6/12 or better with pinhole approximation. Posterior capsule opacities were the most common principal postoperative cause for a deterioration of visual acuity in both groups. Postoperatve trauma was a common cause for a low best-corrected visual acuity n the Aboriginal group but not in the non-Aboriginal group. The majority (75.5%) of Aboriginal patients were satisfied with their operated eyes. Patients who were dissatisfied all had a visual acuity worse than 6/36. Aborigina patients reported worse visual function than did those in the non-Aboriginal group. Cataract surgery has a beneficial effect on the visual acuity and quality of life of Aboriginal and non-Aboriginal people. As compared to their non-Aboriginal counterparts, most Aboriginal people underwent surgery when they were legally blind, had a lower level of attained postoperative visual acuity and a high incidence of uncorrected refractive errors and posterior capsular opacification requiring laser capsulotomy. The positive mpact of cataract surgery on the lives of the majority of Aboriginal patients is highlighted, as is the need for continued postoperative follow up.