The high burden of comorbidities in Aboriginal and Torres Strait Islander Australians living with chronic hepatitis B in Far North Queensland, Australia, and the implications for patient management

Melioidosis in people living with diabetes; clinical presentation, clinical course and implications for patient management

BACKGROUND

Despite the well-established link between diabetes mellitus and melioidosis, the precise impact of diabetes, its complications, and its therapy on the presentation and clinical course of melioidosis is incompletely defined. The influence of glycaemic control on the diverse clinical manifestations and the clinical course of melioidosis in patients with diabetes has also not been examined in detail.

METHODS

We examined all cases of culture-confirmed melioidosis in Far North Queensland, Australia between October 1, 2016, and April 30, 2024. We hoped to define the impact of diabetes, its control and its therapy on the patients' presentation and their clinical course.

RESULTS

There were 321 cases of culture-confirmed melioidosis during the study period; the patients' median (interquartile range (IQR)) age was 57 (46-69) years, 212/321 (66 %) were male, 130/321 (41 %) identified as First Nations Australians. Diabetes was the most common risk factor for melioidosis in the cohort (163/321, 51 %); in 19/163 (12 %) this was a new diagnosis. The median (IQR)) glycosylated haemoglobin prior to presentation was 9.1 % (7.2-11.5) and 96/162 (59 %) with complete data had established macrovascular or microvascular complications. People with diabetes were more likely - than people without diabetes - to have involvement of the liver (odds ratio (OR) 95 % confidence interval (CI): 9.68 (2.21-42.46), p = 0.003), the spleen (OR (95 % CI): 7.32 (1.64-32.80), p = 0.009) or to have disseminated disease (OR (95 % CI): 2.93 (1.26-6.78), p = 0.01). However, people with diabetes were no more likely than people without diabetes to require intensive care unit admission (OR (95 % CI): 0.82 (0.47-1.42), p = 0.48) or to die before hospital discharge (12/163 (7 %) versus 19/158 (12 %), OR (95 % CI): 0.58 (0.27-1.24), p = 0.16). Only 58/163 (36 %) with diabetes had specialist endocrinology review during their hospitalisation and only 22/72 (31 %) with accessible data had good glycaemic control (glycosylated haemoglobin ≤7 %) in the 12 months after discharge, increasing their risk of subsequent diabetic complications. Of the 151 people with diabetes surviving their hospitalisation, 26 (17 %) died, at a median (IQR) of 1.0 (0.40-4.1) years after discharge. Of the individuals with diabetes who had completed five years of follow up, 21/60 (35 %) had died at a median (IQR) age of 67 (51-84) years.

CONCLUSIONS

Individuals with diabetes and melioidosis are more likely to have liver and spleen abscesses and disseminated disease than individuals without diabetes, manifestations that appear to be linked directly to glycaemic control. In Australia's well-resourced health system <10 % of patients with diabetes and melioidosis will die from their infection. However, five-year all-cause mortality in individuals with diabetes who survive their melioidosis is greater than 30 %, emphasising the importance of close, holistic multidisciplinary follow-up to ensure their optimal long-term health outcomes.

Microbiological and Clinical Features of Patients with Cellulitis in Tropical Australia: Disease Severity Assessment and Implications for Clinical Management

Australian guidelines for the treatment of cellulitis are informed by data from temperate, metropolitan centers. It is uncertain if these guidelines are equally applicable in tropical Australia, where the population, access to healthcare, and array of potential pathogens are quite different. This retrospective study examined adults admitted to Cairns Hospital in tropical Queensland, Australia, who were treated with intravenous antibiotics for a principal diagnosis of cellulitis in 2019. The study aimed to describe the epidemiological, clinical, and microbiological findings in these cases and the resulting implications for patient management. There were 305 episodes of cellulitis; a potential pathogen was identified in 93/305 (30%), most commonly Staphylococcus aureus (45/93, 48%) or Group A Streptococcus (16/93, 17%). There was one case of Burkholderia pseudomallei. Initial treatment was most commonly with narrow spectrum β-lactam antibiotics with flucloxacillin prescribed in 170/305 (56%) and cefazolin prescribed in 74/305 (26%). Overall, 4/305 (1%) died or were admitted to the intensive care unit (ICU) within 30 days, 123/305 (40%) had an inpatient stay >48 hours, and 63/305 (21%) were readmitted to hospital within 30 days. Every patient who subsequently died or required ICU admission had an elevated early warning score (EWS ≥3) on admission. An EWS ≥3 on admission also predicted an inpatient stay of >48 hours (odds ratio [OR]: 3.2, 95% CI: 1.7-6.0; P <0.001) and 30-day readmission (OR: 2.3, 95% CI: 1.2-4.6; P = 0.01). The etiology of cellulitis in tropical Queensland, Australia, is very similar to that seen in temperate regions, enabling the use of standard management algorithms for patients with cellulitis in the region.

Chronic hepatitis B care in regional Australia: implications for clinical practice and public health policy

BACKGROUND

Australia is struggling to meet its National Hepatitis B Strategy care targets, particularly in nonmetropolitan settings. It is vital to engage priority populations and improve their access to recommended care to reach these targets.

AIMS

This retrospective study examined people living with chronic hepatitis B (CHB) in regional North Queensland, Australia, and determined whether their care adhered to current national CHB management guidelines. The analysis aimed to identify gaps in care that might be addressed to improve future outcomes.

METHODS

All individuals referred to the gastroenterology clinic at the Townsville University Hospital in regional North Queensland, Australia, for CHB care between January 2015 and December 2020 were identified. Their linkage to care, engagement in care and receipt of guideline-recommended CHB care were determined.

RESULTS

Of 255 individuals, 245 (96%) were linked to care; 108 (42%) remained engaged in care and 86 (38%) were receiving guideline-recommended care in 2021. There were 91/255 (36%) who identified as Indigenous Australians. Indigenous status was the only independent predictor of not being linked to care (odds ratio (OR): 0.13 (95% confidence interval (CI): 0.03-0.60), P = 0.01), not being engaged in care (OR: 0.19 (95% CI: 0.10-0.36), P < 0.0001), not receiving guideline-recommended CHB care (OR: 0.16 (95% CI: 0.08-0.31), P < 0.0001) or not being engaged in a hepatocellular carcinoma surveillance programme (OR: 0.08 (95% CI: 0.02-0.27), P < 0.0001).

CONCLUSION

Current approaches are failing to deliver optimal CHB care to Indigenous Australians in regional North Queensland. Targeted strategies to ensure that Indigenous Australians in the region receive equitable care are urgently needed.

Development of a predictive nomogram for in-hospital death risk in multimorbid patients with hepatocellular carcinoma undergoing Palliative Locoregional Therapy

Patients diagnosed with hepatocellular carcinoma (HCC) often present with multimorbidity, significantly contributing to adverse outcomes, particularly in-hospital mortality. This study aimed to develop a predictive nomogram to assess the impact of comorbidities on in-hospital mortality risk in HCC patients undergoing palliative locoregional therapy. We retrospectively analyzed data from 345 hospitalized HCC patients who underwent palliative locoregional therapy between January 2015 and December 2022. The nomogram was constructed using independent risk factors such as length of stay (LOS), hepatitis B virus (HBV) infection, hypertension, chronic obstructive pulmonary disease (COPD), anemia, thrombocytopenia, liver cirrhosis, hepatic encephalopathy (HE), N stage, and microvascular invasion. The model demonstrated high predictive accuracy with an AUC of 0.908 (95% CI: 0.859-0.956) for the overall dataset, 0.926 (95% CI: 0.883-0.968) for the training set, and 0.862 (95% CI: 0.728-0.994) for the validation set. Calibration curves indicated a strong correlation between predicted and observed outcomes, validated by statistical tests. Decision curve analysis (DCA) and clinical impact curves (CIC) confirmed the model's clinical utility in predicting in-hospital mortality. This nomogram offers a practical tool for personalized risk assessment in HCC patients undergoing palliative locoregional therapy, facilitating informed clinical decision-making and improving patient management.

Hepatitis B genotypes in Aboriginal and Torres Strait Islander Australians: correlation with clinical course and implications for management

BACKGROUND

The prevalence of chronic hepatitis B (CHB) in Aboriginal and Torres Strait Islander Australians in Far North Queensland (FNQ) is greater than twice that of the general Australian population. CHB is common in Torres Strait Islanders diagnosed with hepatocellular carcinoma (HCC) - and in Aboriginals with HCC living in the Northern Territory - however, Aboriginals diagnosed with HCC in FNQ very rarely have CHB. The explanation for this apparent disparity is uncertain.

AIMS

To determine the HBV genotypes in the FNQ Aboriginal and Torres Strait Islander population and their correlation with clinical phenotype.

METHODS

We determined the HBV genotype of Aboriginal and Torres Strait Islander Australians living with CHB in FNQ and correlated this with demographic and clinical findings.

RESULTS

134/197 (68%) enrolled individuals had a sufficient viral load for genotyping. All 40 people with HBV/D genotype had Aboriginal heritage, whereas 85/93 (91%) with HBV/C had Torres Strait Islander heritage (P < 0.0001). Individuals with HBV/D were younger than those with HBV/C (median (interquartile range) age: 43 (39-48) vs 53 (42-66) years, P = 0.0002). However, they were less likely to be HBeAg positive (1/40 (3%) vs 23/93 (25%), P = 0.001). All three HCCs developed in Torres Strait Islanders; two-thirds were infected with HBV/C14; genotyping was not possible in the other individual. All 10 diagnoses of cirrhosis occurred in Torres Strait Islanders, 6/10 were infected with HBV/C14, genotyping was not possible in the other four individuals.

CONCLUSIONS

HBV genotypes in Aboriginal and Torres Strait Islander Australians in FNQ differ markedly, which could explain the significant differences in the clinical phenotype in the two populations and might be used to inform cost-effective CHB care in the region.

Molecular epidemiology of hepatitis B among Indigenous Australians in Queensland and the Torres Strait Islands

BACKGROUND

Chronic hepatitis B virus (HBV) infection is a major health problem for all Indigenous Australians. Post-2000, Hepatitis B surface antigen prevalence has decreased, although remaining four times higher among Indigenous compared with non-Indigenous people.

AIMS

This study aimed to characterise the HBV from Indigenous populations in Queensland and the Torres Strait Islands.

METHODS

Serum samples were collected, with consent, from people within Queensland Indigenous communities prior to 1990 as part of the Queensland Health vaccination programme. Ethics approval was subsequently obtained to further characterise the HBV from 93 of these stored samples. HBV DNA was extracted and genotype was obtained from 82 samples. HBV full genome sequencing was carried out for a subset of 14 samples.

RESULTS

Seventy-eight samples were identified as genotype C (2 × C12, 3 × C13 and 73 × C14), one sample as genotype A (A2) and three samples as genotype D (1 × D2, 1 × D3 and 1 × D4). The HBV/C sequences identified were most closely related to sequences isolated from Papua New Guinea and Indonesia (Papua Province).

CONCLUSIONS

The HBV isolated from the Torres Strait Islanders was notably different to the HBV/C4 strain isolated from Indigenous people of mainland northern Australia, with no evidence of recombination. This reflects the differences in culture and origin between Torres Strait Islanders and mainland Indigenous people.