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Russell DJ, Zhao Y, Mathew S, Fitts MS, Johnson R, Reeve DM, Honan B, Niclasen P, Liddle Z, Green D, Wakerman J. The efficiency, timeliness, health outcomes and cost-effectiveness of a new aeromedical retrieval model in Central Australia: A pre- and post-implementation observational study. Aust J Rural Health 2024; 32:17-28. [PMID: 37916478 DOI: 10.1111/ajr.13057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 10/01/2023] [Accepted: 10/15/2023] [Indexed: 11/03/2023] Open
Abstract
OBJECTIVE To assess timeliness, efficiency, health outcomes and cost-effectiveness of the 2018 redesigned Central Australian aeromedical retrieval model. DESIGN Pre- and postimplementation observational study of all patients receiving telehealth consultations from remote medical practitioners (RMPs) or Medical Retrieval and Consultation Centre (MRaCC) physicians between 1/1/2015 and 29/2/2020. Descriptive and inferential statistics measuring system efficiency, timeliness, health outcomes and incremental cost-effectiveness. FINDINGS There were 9%-10% reductions in rates of total aeromedical retrievals, emergency department admissions and hospitalisations postimplementation, all p-values < 0.001. Usage rates for total hospital bed days and ICU hours were 17% lower (both p < 0.001). After adjusting for periodicity (12% fewer retrievals on weekends), each postimplementation year, there were 0.7 fewer retrievals/day (p = 0.002). The mean time from initial consultation to aeromedical departure declined by 18 minutes post-implementation (115 vs. 97 min, p = 0.007). The hazard of death within 365 days was nonsignificant (0.912, 95% CI 0.743-1.120). Postimplementation, it cost $302 more per hospital admission and $3051 more per year of life saved, with a 75% probability of cost-effectiveness. These costs excluded estimated savings of $744,528/year in reduced hospitalisations and the substantial social and out-of-pocket costs to patients and their families associated with temporary relocation to Alice Springs. CONCLUSION Central Australia's new critical care consultant-led aeromedical retrieval model is more efficient, is dispatched faster and is more cost-effective. These findings are highly relevant to other remote regions in Australia and internationally that have comparable GP-led retrieval services.
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Affiliation(s)
- Deborah Jane Russell
- Menzies School of Health Research, Charles Darwin University, Alice Springs, Northern Territory, Australia
| | - Yuejen Zhao
- Northern Territory Department of Health, Health Statistics and Informatics, Darwin, Northern Territory, Australia
| | - Supriya Mathew
- Menzies School of Health Research, Charles Darwin University, Alice Springs, Northern Territory, Australia
| | - Michelle Susannah Fitts
- Menzies School of Health Research, Charles Darwin University, Alice Springs, Northern Territory, Australia
| | - Richard Johnson
- Northern Territory Health, Central Australian Health Service, The Gap, Northern Territory, Australia
| | - David Mark Reeve
- Northern Territory Health, Central Australian Health Service, The Gap, Northern Territory, Australia
| | - Bridget Honan
- Northern Territory Health, Central Australian Health Service, The Gap, Northern Territory, Australia
| | - Petra Niclasen
- Northern Territory Health, Central Australian Health Service, The Gap, Northern Territory, Australia
| | - Zania Liddle
- Menzies School of Health Research, Charles Darwin University, Alice Springs, Northern Territory, Australia
| | - Danielle Green
- Northern Territory Department of Health, Health Statistics and Informatics, Darwin, Northern Territory, Australia
| | - John Wakerman
- Menzies School of Health Research, Charles Darwin University, Alice Springs, Northern Territory, Australia
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Inglis TJJ. Speaking of sepsis: semantics, syntax, and slang. Front Med (Lausanne) 2023; 10:1250499. [PMID: 37942414 PMCID: PMC10627927 DOI: 10.3389/fmed.2023.1250499] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/15/2023] [Indexed: 11/10/2023] Open
Abstract
Medical language is in a constant state of evolution. Its grammar and vocabulary are not fixed by rigid rules. The interdisciplinary field of sepsis has become a meeting point for new insights arising from advances in systems biology, epidemiology, mechanistic understandings of disease process and antimicrobial interventions. This convergence has gained from our recent experience of SARS-CoV-2 infection and COVID-19 and possibilities inferred from emerging information technology. Biomedical descriptors have diverged along disciplinary lines creating an unfortunate disconnect between clinical and laboratory-based terminology. The resulting confusion between clinically determined sepsis and laboratory verified bloodstream infection raises practical questions that affect daily operational processes in the ward, clinic and laboratory. There is an urgent need to understand how the clinical sepsis pathway and corresponding clinical laboratory workflow can be better aligned as a single coherent entity. There is also an implicit need to understand how this process should produce actionable information in a timely and orderly manner, and identify residual obselete terminology that has crept into common usage. A widely accepted sepsis epistemology, ontology and heuristic will help us improve our clinical management of sepsis.
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Affiliation(s)
- Tim J. J. Inglis
- Western Australian Country Health Service, Perth, WA, Australia
- Schools of Medicine and Biomedical Sciences, University of Western Australia, Crawley, WA, Australia
- Departments of Microbiology, PathWest Laboratory Medicine WA, QEII Medical Centre, and Fiona Stanley Hospital, Nedlands, WA, Australia
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Wu J, Li L, Luo J. Diagnostic and Prognostic Value of Monocyte Distribution Width in Sepsis. J Inflamm Res 2022; 15:4107-4117. [PMID: 35898818 PMCID: PMC9309295 DOI: 10.2147/jir.s372666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/14/2022] [Indexed: 11/26/2022] Open
Abstract
Monocyte distribution width (MDW) is a blood monocyte morphological parameter that can be easily detected by an automated hemocyte analyzer and can provide clinicians with important information about cell volume variability in peripheral blood monocyte populations. The United States' Food and Drug Administration and Conformite Europeenne have both been cleared for their clinical application in the detection of sepsis and developing sepsis in adult patients in the emergency department (ED). Recently, MDW has been found to have an early diagnosis and predictive value for sepsis in neonates and COVID-19 patients. Here, we summarize the findings of the studies investigating the clinical application of MDW in sepsis. Under different stimuli, especially in infectious diseases, the activation of innate immunity is the host's first defense mechanism, and the change in monocyte volume is considered an early indicator reflecting the state of activation of innate immunity. Pivotal study data from a large multicenter patient cohort showed that abnormal MDW at presentation increases the odds of sepsis, considering the combination of MDW and White Blood Cell Count (WBC) as part of a standard sepsis assessment protocol for ED, which may increase the sensitivity and specificity of sepsis diagnosis. Meanwhile, MDW shares a diagnostic performance comparable to that of conventional biomarkers (C-reactive protein and procalcitonin) in sepsis. In addition, some evidence suggests that increased MDW, both in adults and neonates, may be associated with unfavorable short- and long-term outcomes, which indicates its prognostic value in sepsis. Taken together, MDW is a parameter of increased morphological variability of monocytes in response to infection, and numerous studies have shown that MDW could be used as a valuable diagnostic and prognostic index in patients with sepsis or suspected sepsis.
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Affiliation(s)
- Juehui Wu
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, People’s Republic of China
| | - Laisheng Li
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, People’s Republic of China
| | - Jinmei Luo
- Department of Internal Medicine, Medical Intensive Care Unit and Division of Respiratory Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510630, People’s Republic of China
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Mathew S, Russell DJ, Fitts MS, Wakerman J, Honan B, Johnson R, Zhao Y, Reeve D, Niclasen P. Optimising medical retrieval processes and outcomes in remote areas in high‐income countries: A scoping review. Aust J Rural Health 2022; 30:842-857. [DOI: 10.1111/ajr.12908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 05/16/2022] [Accepted: 06/26/2022] [Indexed: 11/27/2022] Open
Affiliation(s)
- Supriya Mathew
- Menzies School of Health Research Charles Darwin University Alice Springs Northern Territory Australia
| | - Deborah J. Russell
- Menzies School of Health Research Charles Darwin University Alice Springs Northern Territory Australia
| | - Michelle S. Fitts
- Menzies School of Health Research Charles Darwin University Alice Springs Northern Territory Australia
| | - John Wakerman
- Menzies School of Health Research Charles Darwin University Alice Springs Northern Territory Australia
| | - Bridget Honan
- Emergency and Retrieval Consultant, Medical Retrieval and Consultation Centre, Central Australian Retrieval Service Alice Springs Hospital Alice Springs Northwest Territories Australia
| | - Richard Johnson
- Emergency and Retrieval Consultant, Medical Retrieval and Consultation Centre, Central Australian Retrieval Service Alice Springs Hospital Alice Springs Northwest Territories Australia
| | - Yuejen Zhao
- Population and Digital Health, Department of Health Northern Territory Government Darwin Northwest Territories Australia
| | - David Reeve
- Primary and Public Health Care, Central Australia Health Service, Department of Health NTG Alice Springs Northwest Territories Australia
| | - Petra Niclasen
- Central Australian Retrieval Service Alice Springs Hospital Alice Springs Northwest Territories Australia
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Age-Dependent Biomarkers for Prediction of In-Hospital Mortality in COVID-19 Patients. J Clin Med 2022; 11:jcm11102682. [PMID: 35628809 PMCID: PMC9144665 DOI: 10.3390/jcm11102682] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/07/2022] [Accepted: 05/07/2022] [Indexed: 01/08/2023] Open
Abstract
Background: Several biomarkers and models have been proposed to predict in-hospital mortality among COVID-19 patients. However, these studies have not examined the association in sub-populations. The present study aimed to identify the association between the two most common inflammatory biomarkers in the emergency department and in-hospital mortality in subgroups of patients. Methods: A historical cohort study of adult patients who were admitted to acute-care hospital between March and December 2020 and had a diagnosis of COVID-19 infection. Data on age, sex, Charlson comorbidity index, white blood cell (WBC) count, C-reactive protein (CRP), and in-hospital mortality were collected. Discrimination ability of each biomarker was observed and the CHAID method was used to identify the association in subgroups of patients. Results: Overall, 762 patients (median age 70.9 years, 59.7% males) were included in the study. Of them, 25.1% died during hospitalization. In-hospital mortality was associated with higher CRP (median 138 mg/L vs. 85 mg/L, p < 0.001), higher WBC count (median 8.5 vs. 6.6 K/µL, p < 0.001), and higher neutrophil-to-lymphocyte ratio (NLR) (median 9.2 vs. 5.4, p < 0.001). The area under the ROC curve was similar among all biomarkers (WBC 0.643, NLR 0.677, CRP 0.646, p > 0.1 for all comparisons). The CHAID method revealed that WBC count was associated with in-hospital mortality in patients aged 43.1−66.0 years (<11 K/µL: 10.1% vs. 11+ K/µL: 27.9%), NLR in patients aged 66.1−80 years (≤8: 15.7%, >8: 43.3%), and CRP in patients aged 80.1+ years (≤47 mg/L: 18.8%, 47.1−149 mg/L: 43.1%, and 149.1+: 71.7% mortality). Conclusions: WBC, NLR, and CRP present similar discrimination abilities. However, each biomarker should be considered as a predictor for in-hospital mortality in different age groups.
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Doran CM, Bryant J, Langham E, Bainbridge R, Begg S, Potts B. Scope and quality of economic evaluations of Aboriginal and Torres Strait Islander health programs: a systematic review. Aust N Z J Public Health 2022; 46:361-369. [PMID: 35298065 DOI: 10.1111/1753-6405.13229] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 12/01/2021] [Accepted: 02/01/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Identify the number, type, scope and quality of economic evaluations of Aboriginal and Torres Strait Islander health programs. METHODS A systematic review of peer-reviewed and grey literature was conducted for articles published from 2010 to 2020 that reported a full economic evaluation of Aboriginal and Torres Strait Islander health programs. Data extraction included: type of economic evaluation, comparators, data sources and concerns, and outcome measures. Methodological quality was assessed using the Drummond checklist. RESULTS Thirteen publications met inclusion criteria: two cost-consequence analyses, two cost-effectiveness analyses, five cost-utility analyses, and four cost-benefit/return on investment analyses. Most studies (n=10) adopted a health system perspective and used a range of key data sources for economic analyses. Ten studies identified data access limitations that restricted analyses and two studies identified data quality concerns. Twelve studies were of good methodological quality and one was of average quality. CONCLUSIONS Despite significant investment in strategies to close the gap in health outcomes for Aboriginal and Torres Strait Islander people, there is limited evidence about what constitutes a cost-effective investment in Aboriginal and Torres Strait Islander healthcare. IMPLICATIONS FOR PUBLIC HEALTH More economic evaluation is required to justify the significant investment in health programs for Aboriginal and Torres Strait Islander people.
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Affiliation(s)
- Christopher M Doran
- Cluster for Resilience and Wellbeing, Appleton Institute, Central Queensland University, Queensland.,Centre for Indigenous Health Equity Research, Central Queensland University, Queensland
| | - Jamie Bryant
- Health Behaviour Research Collaborative, School of Medicine and Public Health, College of Medicine and Wellbeing, University of Newcastle, New South Wales.,Hunter Medical Research Institute, New South Wales
| | - Erika Langham
- School of Population Health, University of Queensland, Queensland
| | - Roxanne Bainbridge
- Cluster for Resilience and Wellbeing, Appleton Institute, Central Queensland University, Queensland
| | - Stephen Begg
- Violet Vines Marshman Centre for Rural Health Research, La Trobe University, Victoria
| | - Boyd Potts
- Cluster for Resilience and Wellbeing, Appleton Institute, Central Queensland University, Queensland.,Centre for Indigenous Health Equity Research, Central Queensland University, Queensland
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7
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Lingervelder D, Koffijberg H, Kusters R, IJzerman MJ. Health Economic Evidence of Point-of-Care Testing: A Systematic Review. PHARMACOECONOMICS - OPEN 2021; 5:157-173. [PMID: 33405188 PMCID: PMC8160040 DOI: 10.1007/s41669-020-00248-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/12/2020] [Indexed: 05/05/2023]
Abstract
OBJECTIVE Point-of-care testing (POCT) has become an essential diagnostic technology for optimal patient care. Its implementation, however, still falls behind. This paper reviews the available evidence on the health economic impact of introducing POCT to assess if poor POCT uptake may be related to lacking evidence. STUDY DESIGN The Scopus and PubMed databases were searched to identify publications describing a health economic evaluation of a point-of-care (POC) test. Data were extracted from the included publications, including general and methodological characteristics as well as the study results summarized in either cost, effects or an incremental cost-effectiveness ratio. Results were sorted into six groups according to the POC test's purpose (diagnosis, screening or monitoring) and care setting (primary care or secondary care). The reporting quality of the publications was determined using the CHEERS checklist. RESULTS The initial search resulted in 396 publications, of which 44 met the inclusion criteria. Most of the evaluations were performed in a primary care setting (n = 31; 70.5%) compared with a secondary care setting (n = 13; 29.5%). About two thirds of the evaluations were on POC tests implemented with a diagnostic purpose (n = 28; 63.6%). More than 75% of evaluations concluded that POCT is recommended for implementation, although in some cases only under specific circumstances and conditions. Compliance with the CHEERS checklist items ranged from 20.8% to 100%, with an average reporting quality of 72.0%. CONCLUSION There were very few evaluations in this review that advised against the implementation of POCT. However, the uptake of POCT in many countries remains low. Even though the evaluations included in this review did not always include the full long-term benefits of POCT, it is clear that health economic evidence across a few dimensions of value already indicate the benefits of POCT. This suggests that the lack of evidence on POCT is not the primary barrier to its implementation and that the low uptake of these tests in clinical practice is due to (a combination of) other barriers. In this context, aspects around organization of care, support of clinicians and quality management may be crucial in the widespread implementation of POCT.
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Affiliation(s)
- Deon Lingervelder
- Health Technology and Services Research Department, Technical Medical Centre, University of Twente, P.O. Box 217, Enschede, 7500 AE, The Netherlands
| | - Hendrik Koffijberg
- Health Technology and Services Research Department, Technical Medical Centre, University of Twente, P.O. Box 217, Enschede, 7500 AE, The Netherlands
| | - Ron Kusters
- Health Technology and Services Research Department, Technical Medical Centre, University of Twente, P.O. Box 217, Enschede, 7500 AE, The Netherlands
- Laboratory for Clinical Chemistry and Haematology, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | - Maarten J IJzerman
- Health Technology and Services Research Department, Technical Medical Centre, University of Twente, P.O. Box 217, Enschede, 7500 AE, The Netherlands.
- Cancer Health Services Research Unit, School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.
- Victorian Comprehensive Cancer Centre, Melbourne, Australia.
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8
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Frank O, Stocks N, Del Mar C. Does point-of-care testing in general practice for leucocyte and differential count change use of antimicrobial medicines? A pilot study. Aust J Prim Health 2020; 26:358-361. [PMID: 32972510 DOI: 10.1071/py20115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/22/2020] [Indexed: 11/23/2022]
Abstract
Diagnostic uncertainty when considering prescription of antimicrobials ('antibiotics') in primary care contributes to the major problem of microbial resistance. We conducted a feasibility evaluation of rapid testing for leucocyte and differential count in two urban general practices, surveying the GPs online and interviewing them. GPs reported that the machines were easy to use, the test results influenced their care and they would adopt the system if costs were off-set. Feasibility, acceptability and perceived benefit justify a randomised trial to test the effect on antibiotic prescribing rates and quality of care, with an economic evaluation to inform the cost-benefit.
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Affiliation(s)
- Oliver Frank
- Oakden Medical Centre, 132-134 Fosters Road, Hillcrest, SA 5086, Australia; and Discipline of General Practice, Adelaide Medical School, University of Adelaide, Adelaide, SA 5005, Australia; and Corresponding author.
| | - Nigel Stocks
- Discipline of General Practice, Adelaide Medical School, University of Adelaide, Adelaide, SA 5005, Australia
| | - Chris Del Mar
- Institute for Evidence-Based Healthcare, Level 4, Building 5, Faculty of Health Sciences and Medicine, Bond University, 14 University Drive, Robina, Qld 4226, Australia
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Robosa RS, Sandaradura I, Dwyer DE, O'Sullivan MVN. Clinical evaluation of SARS-CoV-2 point-of-care antibody tests. Pathology 2020; 52:783-789. [PMID: 33039095 PMCID: PMC7508500 DOI: 10.1016/j.pathol.2020.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 12/11/2022]
Abstract
The aim of this study was to assess the analytic and clinical performance of four rapid lateral flow point-of-care tests (POCTs) for identifying SARS-CoV-2-specific antibodies. A retrospective study was conducted between 22 January and 30 March 2020 on 132 serum samples for SARS-CoV-2-specific antibody detection referred to a tertiary referral hospital laboratory in New South Wales. Multiple sera were tested from 20 confirmed or suspected COVID-19 patients with SARS-CoV-2-specific antibodies detected by immunofluorescence (IFA) or neutralisation, and 71 SARS-CoV-2 uninfected individuals. We measured the sensitivity and specificity for detection of SARS-CoV-2 IgM and IgG antibodies for each POCT in comparison to positive SARS-CoV-2-specific IFA and viral neutralisation, our current laboratory benchmark tests. All POCTs were found to have a low analytic sensitivity for SARS-CoV-2 antibodies, ranging from 27.3% to 58.2%, with a specificity between 88.3% and 100%, and a low clinical sensitivity from 45% to 65%, with a clinical specificity between 87.3% and 100%. All POCTs had an increased sensitivity when specimens were collected more than 14 days from onset of symptoms. The detection using point-of-care testing of SARS-CoV-2-specific antibodies after disease onset lagged behind IFA by a range of 0–9 days. POCTs promise the benefit of providing quick easy testing for SARS-CoV-2-specific antibodies. However, their poor sensitivity and delayed antibody detection make them unsuitable as a diagnostic or screening tool alone.
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Affiliation(s)
- Roselle S Robosa
- Centre for Infectious Diseases and Microbiology Laboratory Services, New South Wales Health Pathology - Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
| | - Indy Sandaradura
- Centre for Infectious Diseases and Microbiology Laboratory Services, New South Wales Health Pathology - Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Dominic E Dwyer
- Centre for Infectious Diseases and Microbiology Laboratory Services, New South Wales Health Pathology - Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Matthew V N O'Sullivan
- Centre for Infectious Diseases and Microbiology Laboratory Services, New South Wales Health Pathology - Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia.
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