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Objective: The aim of this pilot project was to assess the feasibility of an outreach mobile influenza vaccination program led by a large hospital network targeting high-risk and vulnerable populations in a high-income setting., Methods: Key populations were identified and stakeholders with established access to these populations were engaged. A mobile, nurse-led immunisation service attended sites where these populations attend and offered influenza vaccine. Data was collected on risk factors for severe disease and past vaccination history. Vaccine type and date of administration were entered onto the Australian Immunisation Registry., Results: Sixteen sites were visited, and 520 influenza vaccines were administered. Of those receiving the vaccine, 61% had received it previously, but only 39% in the past 12 months. A total of 232/520 participants (45%) self-reported a risk factor for severe disease., Conclusions: Appropriate identification of vulnerable populations, with good engagement of key stakeholders, can successfully deliver vaccines to sections of the population who may struggle to engage with healthcare services even when they are freely available. Implications for public health: Taking vaccines to vulnerable populations is well received and remains an important strategy to maximise uptake, even within high-income settings with universal access to healthcare., (© 2018 The Authors.)

The role of maternal vaccination in reducing neonatal morbidity and mortality is expanding but uptake remains suboptimal. While the barriers to uptake have been well described, women from minority groups have not been well represented in previous studies. In this study we examine the facilitators and barriers to uptake of antenatal vaccination by women from culturally and linguistically diverse backgrounds in Melbourne, Australia. 537 women attending antenatal care completed a survey; 69% were born overseas. 63% had or intended to receive pertussis vaccine and 57% had or intended to receive influenza vaccine during their pregnancy. On multivariable analysis, predictors of uptake of pertussis vaccine were healthcare provider recommendation (OR 10, 95% CI 5-21, p < 0.001) and belief maternal pertussis vaccination is safe (OR 36, 95% CI 18-70, p < 0.001). For influenza vaccine, predictors of uptake were previous receipt of influenza vaccine (OR 8, 95% CI 5-15, p < 0.001) and healthcare provider recommendation (OR 30, 95% CI 16-56, p < 0.001). Lack of healthcare provider recommendation was the main reason for non-vaccination (17/46, 37%). While most women were aware of and intended to receive recommended vaccinations, recently arrived migrant women (resident in Australia for less than two years) were less likely to be aware of pertussis vaccine (15/22, 68% vs 452/513, 88%, p = 0.01) and less likely to believe it to be safe during pregnancy (4/22, 18% vs 299/514, 58%, p < 0.001). This highlights the important role of healthcare providers in recommending and educating women, particularly newly arrived migrant women, in their decisions about vaccination during pregnancy.

Introduction: In 2015, the World Health Organization recommended that all HIV-infected individuals consider ART initiation as soon as possible after diagnosis. Sex differences in choice of initial ART regimen, indications for switching, time to switching and choice of second-line regimens have not been well described. The aims of this study were to describe first-line ART and CD4 count at ART initiation by sex, calendar year and region, and to analyse time to change or interruption in first-line ART, according to sex in each region., Methods: Participating cohorts included: Southern, East and West Africa (IeDEA-Africa), North America (NA-ACCORD), Caribbean, Central/South America (CCASAnet) and Asia-Pacific including Australia (IeDEA Asia-Pacific). The primary outcomes analysed for each region and according to sex were choice of initial ART, time to switching and time to discontinuation of the first-line regimen., Results and Discussion: The combined cohort data set comprised of 715,252 participants across seven regions from low- to high-income settings. The median CD4 count at treatment initiation was lower in men compared with women in nearly all regions and time periods. Women from North America and Southern Africa were more likely to switch ART compared to men (p < 0.001) with approximately 90% of women reporting a major change after 10 years in North America. Overall, after 8 years on ART, >50% of HIV- positive men and women from Southern Africa, East Africa, South and Central America remained on their original regimen. Men were more likely to have a treatment interruption compared with women in low- and middle-income countries from the Asia/Pacific region (p < 0.001) as were men from Southern Africa (p < 0.001). Greater than 75% of men and women did not report a treatment interruption after 10 years on ART from all regions except North America and Southern Africa., Conclusions: There are regional variations in the ART regimen commenced at baseline and rates of major change and treatment interruption according to sex. Some of this is likely to reflect changes in local and international antiretroviral guideline recommendations but other sex-specific factors such as pregnancy may contribute to these differences., (© 2018 The Authors. Journal of the International AIDS Society published by John Wiley & sons Ltd on behalf of the International AIDS Society.)

Maternal vaccination is a safe and effective strategy to reduce maternal and neonatal morbidity and mortality from pertussis and influenza. However, despite recommendations for maternal vaccination since 2010, uptake remains suboptimal. Barriers to uptake have been studied widely and include lack of integration of vaccination into routine pregnancy care and access to vaccination services. Standing orders for administration of vaccines without the need for a physician review or prescription have been demonstrated to improve uptake as part of multi-model interventions to increase antenatal influenza and post-partum pertussis vaccination. Monash Health is a university-affiliated, public healthcare network in Melbourne, Australia providing maternity services across three hospitals. In this study we compared three different immunisation models - an immunisation nurse-led immunisation service, standing orders for midwife-administered pertussis vaccination within pregnancy care clinics, and delivery by general practitioners in primary care. Uptake of maternal pertussis vaccine was measured as recorded in the state-wide perinatal data collection tool. Uptake improved significantly at all three hospitals over the study period with the most significant change (39% to 91%, p < .001) noted at the hospital where standing orders were introduced. Our study highlights the diversity of immunisation service models available in maternity care settings. We demonstrated significant improvement in uptake of maternal pertussis vaccination with introduction of midwife-administered vaccination but each maternity service should consider the model best suited to their needs., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objectives: We quantified concomitant medication polypharmacy, pharmacokinetic and pharmacodynamic interactions, adverse effects and adherence in Australian adults on effective antiretroviral therapy., Design: Cross-sectional., Methods: Patients recruited into a nationwide cohort and assessed for prevalence and type of concomitant medication (including polypharmacy, defined as ≥5 concomitant medications), pharmacokinetic or pharmacodynamic interactions, potential concomitant medication adverse effects and concomitant medication adherence. Factors associated with concomitant medication polypharmacy and with imperfect adherence were identified using multivariable logistic regression., Results: Of 522 participants, 392 (75%) took a concomitant medication (mostly cardiovascular, nonprescription or antidepressant). Overall, 280 participants (54%) had polypharmacy of concomitant medications and/or a drug interaction or contraindication. Polypharmacy was present in 122 (23%) and independently associated with clinical trial participation, renal impairment, major comorbidity, hospital/general practice-based HIV care (versus sexual health clinic) and benzodiazepine use. Seventeen participants (3%) took at least one concomitant medication contraindicated with their antiretroviral therapy, and 237 (45%) had at least one pharmacokinetic/pharmacodynamic interaction. Concomitant medication use was significantly associated with sleep disturbance and myalgia, and polypharmacy of concomitant medications with diarrhoea, fatigue, myalgia and peripheral neuropathy. Sixty participants (12%) reported imperfect concomitant medication adherence, independently associated with requiring financial support, foregoing necessities for financial reasons, good/very good self-reported general health and at least 1 bed day for illness in the previous 12 months., Conclusion: In a resource-rich setting with universal healthcare access, the majority of this sample took a concomitant medication. Over half had at least one of concomitant medication polypharmacy, pharmacokinetic or pharmacodynamic interaction. Concomitant medication use was associated with several adverse clinical outcomes.

Objective(s): While antenatal vaccination is the most effective strategy to reduce newborn pertussis infection and its associated morbidity and mortality, uptake has consistently been reported to be suboptimal. "Cocooning" or vaccination of the close contacts of newborns therefore remains an important strategy for protecting newborns when maternal vaccination has not occurred or with insufficient time for antibody transfer. This study assesses the uptake of pertussis vaccination by parents and close contacts of newborns providing insight into the vulnerability of newborns to pertussis upon discharge from hospital to their primary carers., Study Design: The study was conducted at three public and two private hospitals in Melbourne, Australia. A survey was administered to 689 women and/or their partners admitted on maternity wards of participating hospitals after delivery of a healthy newborn between August and December 2016. The main outcomes measured were reported vaccination rates and factors associated with uptake of pertussis vaccination. Kappa statistic and logistic regression were used to determine factors associated with vaccination., Results: 70% of women and 66% of partners reported pertussis vaccination according to national recommendations. Significantly 22% of newborns were discharged to a household where neither parent reported vaccination. Compared to when maternal vaccination did occur, in families where it didn't there were low rates of vaccination of partners (83% vs 26%) and other carers, particularly carers usually resident overseas (76% vs 18.5%)., Conclusion(s): While the majority of mothers and partners reported pertussis vaccination in accordance with recommended guidelines, concerningly nearly a quarter of newborns were discharged to a home where neither parent was vaccinated. When maternal vaccination did not occur, rates of vaccination of the other close contacts was poor. Educating women to encourage vaccination of partners and carers particularly those coming from overseas, prior to their arrival is an important consideration when maternal immunization does not occur. Cocooning remains an important approach to protect newborns of mothers vaccinated late or not vaccinated in pregnancy., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Congenital cytomegalovirus is the most frequent, yet under-recognised, infectious cause of newborn malformation in developed countries. Despite its clinical and public health importance, questions remain regarding the best diagnostic methods for identifying maternal and neonatal infection, and regarding optimal prevention and therapeutic strategies for infected mothers and neonates. The absence of guidelines impairs global efforts to decrease the effect of congenital cytomegalovirus. Data in the literature suggest that congenital cytomegalovirus infection remains a research priority, but data are yet to be translated into clinical practice. An informal International Congenital Cytomegalovirus Recommendations Group was convened in 2015 to address these questions and to provide recommendations for prevention, diagnosis, and treatment. On the basis of consensus discussions and a review of the literature, we do not support universal screening of mothers and the routine use of cytomegalovirus immunoglobulin for prophylaxis or treatment of infected mothers. However, treatment guidelines for infected neonates were recommended. Consideration must be given to universal neonatal screening for cytomegalovirus to facilitate early detection and intervention for sensorineural hearing loss and developmental delay, where appropriate. The group agreed that education and prevention strategies for mothers were beneficial, and that recommendations will need continual updating as further data become available., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Establishing a baby biome through the controversial practice of 'vaginal seeding' has generated interest among the general public and healthcare providers alike. We discuss the potential risks of this practice and offer a harm minimisation approach to managing women requesting vaginal microbiome transfer after delivery by caesarean section., (© 2017 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Introduction: Criminal cases involving human immunodeficiency virus transmission or exposure require that courts correctly comprehend the rapidly evolving science of HIV transmission and the impact of an HIV diagnosis. This consensus statement, written by leading HIV clinicians and scientists, provides current scientific evidence to facilitate just outcomes in Australian criminal cases involving HIV.Main recommendations: Caution should be exercised when considering charges or prosecutions regarding HIV transmission or exposure because:Scientific evidence shows that the risk of HIV transmission during sex between partners of different HIV serostatus can be low, negligible or too low to quantify, even when the HIV-positive partner is not taking effective antiretroviral therapy, depending on the nature of the sexual act, the viral load of the partner with HIV, and whether a condom or pre-exposure prophylaxis is employed to reduce risk.The use of phylogenetic analysis in cases of suspected HIV transmission requires careful consideration of its limited probative value as evidence of causation of HIV infection, although such an approach may provide valuable information, particularly in relation to excluding HIV transmission between individuals.Most people recently infected with HIV are able to commence simple treatment providing them a normal and healthy life expectancy, largely comparable with their HIV-negative peers. Among people who have been diagnosed and are receiving treatment, HIV is rarely life threatening. People with HIV can conceive children with negligible risk to their partner and low risk to their child.Changes in management as result of the consensus statement: Given the limited risk of HIV transmission per sexual act and the limited long term harms experienced by most people recently diagnosed with HIV, appropriate care should be taken before HIV prosecutions are pursued. Careful attention should be paid to the best scientific evidence on HIV risk and harms, with consideration given to alternatives to prosecution, including public health management.

Background: There is an increasing incidence of pertussis infection in infants too young to be adequately protected via vaccination. Maternal pertussis vaccination during the third trimester of pregnancy is a new strategy to provide protection to newborn infants., Objective: This study sought to determine the optimal gestational window for vaccination in the third trimester., Study Design: This prospective study recruited 3 groups of women: an early vaccination group, vaccinated between 28-32 weeks' gestation; a late vaccination group, vaccinated between 33-36 weeks' gestation; and an unvaccinated control group. Maternal venous blood was taken prior to pertussis vaccination. At birth, infant cord blood was collected to determine antibody levels to pertussis toxin (PT), pertactin (PRN), and filamentous hemagglutinin (FHA)., Results: In all, 154 women were recruited from April through September 2014. There was no significant difference between maternal PRN and FHA antibody levels among the 3 groups, however, PT was higher in the early compared to late vaccination group (P = .05). Cord blood antibody levels to PT, PRN, and FHA were significantly higher in those born to vaccinated women compared with unvaccinated controls (P < .001, P = .001, and P < .001, respectively). Vaccination between 28-32 weeks' gestation resulted in significantly higher cord blood PT (4.18.0 vs 3.50 IU/mL, P = .009), PRN (5.83 vs 5.31 IU/mL, P = .03), and FHA (5.56 vs 5.03 IU/mL, P = .03) antibody levels than vaccination between 33-36 weeks' gestation. When adjusted for maternal prevaccination antibody levels, PT levels in early vs late vaccination approached significance (P = .06). PRN levels were significantly higher in the early vaccination group (P = .003). There was no significant difference for FHA antibody levels between the 2 groups (P = .16)., Conclusion: Maternal vaccination during the third trimester is effective in affording higher levels of pertussis antibody protection to the newborn infant. Vaccination early in the third trimester appears more effective than later in pregnancy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Unlabelled: Background Gender differences vary across geographical settings and are poorly reported in the literature. The aim of this study was to evaluate demographics and clinical characteristics of participants from the Australian HIV Observational Database (AHOD), and to explore any differences between females and males in the rate of new clinical outcomes, as well as initial immunological and virological response to antiretroviral therapy., Methods: Time to a new clinical end-point, all-cause mortality and/or AIDS illness was analysed using standard survival methods. Univariate and covariate adjusted Cox proportional hazard models were used to evaluate the time to plasma viral load suppression in all patients that initiated antiretroviral therapy (ART) and time to switching from a first-line ART to a second-line ART regimen., Results: There was no significant difference between females and males for the hazard of all-cause mortality [adjusted hazard ratio: 0.98 (0.51, 1.55), P=0.67], new AIDS illness [adjusted hazard ratio: 0.75 (0.38, 1.48), P=0.41] or a composite end-point [adjusted hazard ratio: 0.74 (0.45, 1.21), P=0.23]. Incident rates of all-cause mortality were similar between females and males; 1.14 (0.61, 1.95) vs 1.28 (1.12, 1.45) per 100 person years. Virological response to ART was similar for females and males when measured as time to viral suppression and/or time to virological failure., Conclusion: This study supports current Australian HIV clinical care as providing equivalent standards of care for male and female HIV-positive patients. Future studies should compare ART-associated toxicity differences between ART-associated toxicity differences between men and women living with HIV in Australia.

Objectives: Contraceptive use is important for reproductive-aged women living with HIV to plan and optimise safety of pregnancies. Clinicians play a vital role in counselling patients about contraception and safe sexual activity. This study aimed to determine the frequency and predictors of discussions regarding sexual activity and contraceptive use., Methods: Retrospective clinical study of all reproductive-aged women (n=128) treated for HIV between 2010 and 2012 at two metropolitan hospitals. Evidence of discussion between treating doctors and patients regarding sexual activity and contraception and variables including patient age, gender of doctor, time since HIV diagnosis, previous pregnancy, country of birth and antiretroviral regimen were obtained from medical records., Results: Sexual activity status was documented for 54% of the women and discussion regarding contraception was recorded for less than one-third of the study participants. Contraceptive use was not recorded in 63% of the medical records. In the study cohort 27% of the women used contraception, 10% did not use contraception, and when a discussion regarding sexual activity was documented, contraception was 3.7 times more likely to also be discussed (p=0.04). Excluding women who were pregnant, women who were documented as using contraception were 1.8 times as likely to have had a discussion about contraception documented (p=0.05). After adjustment for other factors, previous pregnancy, gender of doctor and age of patient were not associated with discussions regarding sexual activity or contraception., Conclusions: Discussions regarding sexual activity and contraception between HIV-infected women of reproductive age and their clinicians were inconsistent and suboptimal. Mechanisms to facilitate regular discussion about sexual activity and contraception between clinicians and women with HIV warrant further investigation., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Unlabelled: Background The characteristics associated with incident hepatitis B (HBV) infection in HIV-positive individuals are not well described in the Australian setting. The aim of this study is to determine the characteristics of and risk factors for HBV infection within HIV-infected individuals in a Melbourne cohort between 1985 and 2011., Methods: Individuals susceptible to HBV at their HIV diagnosis were identified using their HBV serology stored within the Victorian HIV database. Within this group, those who had a subsequent positive test for hepatitis B surface antigen or hepatitis B core antibody were identified as infected with HBV after their HIV diagnosis. Incident cases were matched with controls from the initially susceptible group who did not seroconvert for analysis. An incidence rate was calculated from the number of seroconversions and the cumulative time at risk (in 1000 patient-years of follow-up)., Results: Of the 4711 patients with HIV seen more than once, 3223 had HBV testing. Of the 174 with positive HBV test results, 39 individuals met the definition of seroconversion after HIV diagnosis, representing the incident cases. The estimated HBV incidence rate was 1.81 (95% confidence interval: 1.28-2.47) per 1000 patient-years at risk. These individuals form the basis of a detailed case series and case-control study. Data collected include demographic details, immunological and virological characteristics, antiretroviral treatment and vaccination history., Conclusions: HIV-infected individuals should be screened for HBV and monitored for incident infection. Optimal control of HIV and improved vaccination coverage provide the best opportunity for prevention.

Background: Mother-to-child transmission (MTCT) of hepatitis B virus continues to occur despite the interventions of hepatitis B vaccination and immunoglobulin. The most significant risk factor in transmission is high maternal viral load. Being aware of viral replicative activity permits risk stratification and allows the opportunity for additional preventative measures such as antiviral therapy., Methods: Retrospective audit of investigations and clinical management among hepatitis B surface antigen-positive pregnant women from three maternity services across Victoria over a five-year period from 2006 to 2011., Results: Over the study period at the three institutions, there were 46,855 births, and 398 hepatitis B-positive pregnant women. 87% of the women were non-Australian-born. Viral load testing was performed in <20% of all pregnancies, and hepatitis B e antigen status assessed in 33%. Only 18% of the women with hepatitis B were referred for specialist care, but if referred, they were more likely to have an assessment of viral replicative status performed. Compliance with administration of neonatal hepatitis B immunoglobulin and birth-dose vaccination was high (>90%)., Conclusion: There is scope for considerable improvement in referral and assessment of pregnant women with hepatitis B infection. Guidelines addressing the issue of maternal viral replicative status and the need for antiviral therapy may assist in guiding clinical management., (© 2013 The Authors ANZJOG © 2013 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Cytomegalovirus (CMV) infection is now the commonest congenital form of infective neurological handicap, recognized by the Institute of Medicine as the leading priority for the developed world in congenital infection. In the absence of an effective vaccine, universal screening for CMV in pregnancy has been proposed, in order that primary infection could be diagnosed and- potentially- the burden of disability due to congenital CMV prevented., Discussion: Universal screening for CMV to identify seronegative women at the beginning of pregnancy could potentially reduce the burden of congenital CMV in one of three ways. The risk of acquiring the infection during pregnancy has been shown to be reduced by institution of simple hygiene measures (primary prevention). Among women who seroconvert during pregnancy, CMV hyperimmune globulin (CMV HIG) shows promise in reducing the risk of perinatal transmission (secondary prevention), and CMV HIG and/ or antivirals may be effective in reducing the risk of clinical sequelae among those known to be infected (tertiary prevention). The reports from these studies have re-ignited interest in universal screening for CMV, but against the potential benefit of these exciting therapies needs to be weighed the challenges associated with the implementation of any universal screening in pregnancy. These include; the optimal test, and timing of screening, to maximize detection; an approach to the management of equivocal results, and the cost effectiveness of the proposed screening program. In this article, we provide an overview of current knowledge and ongoing trials in the prevention, diagnosis and management of congenital CMV. Recognising that CMV screening is already being offered to many patients on an ad hoc basis, we also provide a management algorithm to guide clinicians and assist in counseling patients., Summary: We suggest that- on the basis of current data- the criteria necessary to recommend universal screening for CMV are not yet met, but this position is likely to change if trials currently underway confirm that CMV HIG and/ or antivirals are effective in reducing the burden of congenital CMV disease.

In resource rich settings transmission of HIV from mother to child during pregnancy and post partum has been significantly reduced by access to interventions such as maternal and neonatal antiretroviral therapy, avoidance of breast feeding and consideration to caesarean section. Accumulating observational and randomised controlled studies provide the evidence for development of guidelines for the clinical management of these women. However, despite referencing the same studies, differences exist between recommendations originating from the United States versus the United Kingdom. The particular areas of controversy include use of efavirenz, dose adjustment of antiretrovirals during pregnancy, mode of delivery according to maternal viral load, duration of neonatal zidovudine, use of PJP prophylaxis and number of antiretrovirals to prescribe in a neonate considered high risk of acquiring HIV infection. This article summarises these differences and suggests ways of approaching and adapting these conflicting recommendations to the local setting.

Objective: To assess the uptake of influenza vaccination by pregnant women and maternity care providers and explore their attitudes towards influenza vaccination., Design, Setting and Participants: Cross-sectional survey administered in a Victorian tertiary level public hospital to 337 pregnant women and 96 maternity care providers., Results: 31.3% of patients planned to or had received influenza vaccination this year, but only a quarter had received education about influenza. Women were more likely to receive influenza vaccination if they had been vaccinated in the last two years (RR 4.5, 95% CI: 3.1-6.4, p<0.001), received education about influenza (RR 2.3, 95% CI: 1.6-3.2, p<0.001) or believed that they were at high risk of influenza-related complications while pregnant (RR 2.0, 95% CI: 1.4-2.7, p<0.001). While only 56.8% of maternity care providers believed pregnant women were at high risk of influenza-related complications, 72.9% would recommend influenza vaccination to all pregnant women. Of the maternity care providers studied, 69% planned to or had been vaccinated in 2011, with this group more likely to recommend vaccination to their patients (RR 2.0, 95% CI: 1.3-3.0, p<0.001). Significantly more maternity care providers indicated that they would routinely recommend influenza vaccination than the proportion of patients who reported receiving education., Conclusions: Influenza vaccination rates in pregnant women are low, reflecting inadequate patient education despite most maternity care providers indicating that they would routinely recommend influenza vaccination. Increasing influenza vaccination uptake by women in pregnancy will require better education of both women and maternity care providers., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Unlabelled: It is estimated that 350 to 400 million individuals worldwide are chronically infected with hepatitis B virus (HBV). In regions of high endemicity, many of these are females of reproductive age who are an important source for perinatal transmission. There are a number of issues specific to the women of childbearing age who have chronic HBV infection, including the safety of antiviral therapy during pregnancy and breast-feeding, the changes in the immune system during pregnancy and postpartum that may impact on the natural history of HBV, and the emerging role of antivirals to reduce perinatal transmission of HBV. For women in their reproductive years who require treatment, many of the available antivirals have not been studied in pregnant or breast-feeding women and their use requires the development of a carefully considered strategy, considering the impact of both the disease and treatment on the mother and fetus/infant. The purpose of this article is to (1) review data regarding the mechanisms and timing of perinatal HBV infection; (2) review data on interventions, particularly antiviral therapy, to reduce perinatal transmission beyond the protection afforded by hepatitis B immunoglobulin and vaccination; (3) summarize the immunological changes associated with pregnancy and the potential effect these may have on the natural history of HBV infection; and (4) summarize the information currently available for antiviral therapy available for HBV treatment, focusing specifically on safety data pertaining to reproduction, pregnancy, and breast-feeding., Target Audience: Obstetricians & Gynecologists and Family Physicians., Learning Objectives: After completing this CME activity physicians should be better able to classify the interventions to reduce mother-to-child transmission of hepatitis B including antivirals, caesarean section, hepatitis B immunoglobulin and hepatitis B vaccine, assess the immunological changes associated with pregnancy and the potential effect this may have on the natural history of HBV infection and apply the information currently available for antiviral therapy licensed for HBV treatment, focusing specifically on safety data in pregnancy and during breastfeeding.

Objective: To describe the clinical outcomes for all HIV-serodiscordant couples attending an assisted reproduction program., Design, Setting and Participants: Retrospective review of demographic, clinical and outcome data for all HIV-serodiscordant couples who attended an assisted reproduction program at a tertiary hospital in Melbourne, between its commencement in 2003 and June 2010., Main Outcome Measures: Pregnancies, miscarriages, births, HIV transmission to the HIV-negative partner, semen quality and detection of HIV (HIV RNA and HIV DNA) in semen., Results: As of June 2010, 39 HIV-positive clients had proceeded to assisted reproduction after the initial consultation in the program. There were 162 completed cycles, with 26 pregnancies (clinical pregnancy rate per cycle, 16.2% for HIV-positive men with an HIV-negative partner, and 15.4% for HIV-positive women). Of all 222 tested semen samples, 18 (8%) had HIV RNA detected despite these men receiving antiretroviral therapy and having an undetectable HIV viral load in plasma. Sperm velocity was significantly lower in HIV-positive clients receiving combination antiretroviral therapy than in a control group of recipient-recruited sperm donors (P = 0.01); there were no other significant differences in sperm quality between the two groups. No HIV transmission to babies or HIV-negative partners occurred., Conclusion: Our findings show detectable HIV in 8% of semen samples from men with an undetectable HIV viral load in plasma, but confirm the safety of assisted reproduction for HIV-serodiscordant couples within a program with strict protocols for HIV treatment and testing of all semen before use.

Background: Cytomegalovirus (CMV) is a herpesvirus and the most common cause of congenital infection in developed countries. Congenital CMV infection can have devastating consequences to the fetus. The high incidence and the serious morbidity associated with congenital CMV infection emphasise the need for effective interventions to prevent the antenatal transmission of CMV infection., Objectives: The aim of this review was to assess the benefits and harms of interventions used during pregnancy to prevent mother to fetus transmission of CMV infection., Search Strategy: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2010)., Selection Criteria: All randomised controlled trials (RCTs) and quasi RCTs investigating antenatal interventions for preventing the transmission of CMV from the mother to fetus during pregnancy and adverse outcomes in the congenitally infected infant., Data Collection and Analysis: Two review authors independently assessed studies for inclusion., Main Results: We identified six studies from the search. None of these studies met the pre-defined criteria for inclusion in this review., Authors' Conclusions: To date, no RCTs are available that examine antenatal interventions for preventing the transmission of CMV from the infected mother to fetus during pregnancy and adverse outcomes in the congenitally infected infant. Further research is needed to assess the efficacy of interventions aimed at preventing the transmission of CMV from the mother to fetus during pregnancy including a long-term follow-up of exposed infants and a cost effective analysis.

Background: Pregnant women have been identified as a group at risk of increased morbidity and mortality associated with the pandemic H1N1 influenza A 2009 (H1N1/09) outbreak., Methods: Six hospitals in the state of Victoria, Australia, contributed retrospective and prospective demographic and clinical data, reason for admission data, and maternal and fetal outcome data for women with laboratory-confirmed H1N1/09 admitted to the hospital from 20 May 2009 through 31 July 2009., Results: Forty-three cases were reported during the study period, including 8 intensive care unit admissions, 1 maternal death, 2 fetal deaths, and 1 neonatal death. The most common reason for admission was uncomplicated influenza-like illness. Patients hospitalized for uncomplicated influenza-like illness had a length of stay significantly less than those with confirmed pneumonia. Thirty-six percent of women delivered during the hospitalization. Of the women delivering before 37 weeks' gestation, almost all had pneumonia. Almost half of our case series had no other comorbidity, a large proportion (77%) of women received antivirals, and 56% received antibiotics. The incidence of hospitalization was estimated at 0.46% (95% confidence interval, 0.31%-0.66%) of all 6094 pregnant women in the third trimester during the 3-month study period. The incidence of hospitalization in the second trimester was estimated at 0.21% (95% confidence interval, 0.11%-0.36%)., Conclusions: This case series confirms a high number of complications in pregnant women due to pandemic H1N1/09. Many of these women had comorbidities, although almost 50% of the women in this case series who required hospitalization did not have an additional risk factor other than being pregnant.

Objective: To describe the pattern of perinatal HIV exposure and outcomes among children born in Australia, 1982-2006., Design and Setting: National surveillance for perinatal HIV exposure., Participants: Women with HIV infection and their perinatally exposed children., Main Outcome Measures: Trends in the age-standardised rate of perinatal exposure, uptake of interventions by women with an antenatal HIV diagnosis, and rate of mother-to-child transmission., Results: Between 1982 and 2006, there were 354 reported cases of perinatal HIV exposure among children born in Australia. The age-standardised rate of perinatal exposure per 100,000 live births increased from 2.3 (1982-1986) to 5.1 (1991-1998), 9.9 (1999-2002) and 8.3 (2003-2006). Among children whose mother was diagnosed antenatally, the mother-to-child transmission rate declined significantly, from 25% (4/16; 95% CI, 7%-52%) in 1987-1990 to 5% (4/82; 95% CI, 1%-12%) in 2003-2006 (P < 0.001). The rate declined from 8% (4/51; 95% CI, 2%-19%) in 1987-1998 to 1% (2/151; 95% CI, 0.2%-5%) in 1999-2006 among children whose mother used at least two interventions. Mother-to-child transmission remained high among children born to women diagnosed postnatally (39/87, 45%; 95% CI, 34%-56%) and to women diagnosed antenatally who used no interventions (7/15, 47%; 95% CI, 21%-73%)., Conclusion: The increasing rate of perinatal exposure and the decreasing rate of mother-to-child transmission among children whose mothers' HIV infection was diagnosed antenatally were temporally associated with use of interventions for minimising mother-to-child transmission. Mother-to-child transmission remained high when the mother's HIV infection was not known during pregnancy.

Introduction: This study aimed to assess self-reported screening practice in the antenatal setting, factors associated with screening, barriers to universal testing for HIV and follow-up for infants born to hepatitis C virus (HCV)-infected women., Methods: A total of 3100 general practitioners (GPs) were mailed the survey. The half from Victoria was randomised to receive their questionnaire by registered post or regular post. All GPs from New South Wales (NSW) received their questionnaire via regular post., Results: The overall response rate was 70%. Registered post resulted in a higher cumulative response rate compared with regular post (86% vs. 67%P < 0.001). Greater than 90% of respondents always screened for syphilis, rubella and hepatitis B virus. Testing for HIV and HCV approached 66% in NSW. In Victoria more respondents always screen for HCV (72%) compared with HIV-1 (64%). Respondents from NSW were less likely to screen for toxoplasmosis (adjusted odds ratio (AOR) 0.64 (0.43, 0.94) P = 0.02) or HCV (AOR 0.75 (0.61, 0.92) P = 0.005) compared with Victoria. Older respondents were more likely to screen for toxoplasmosis (AOR 1.54 (1.05, 2.27) P = 0.03), cytomegalovirus (OR 1.5 (1.0, 2.1) P = 0.05) and chlamydia (AOR 1.88 (1.27, 2.77) P = 0.002). Of respondents who have managed a pregnant woman with HCV 25% inappropriately test infants for infection before one month of age., Conclusion: This study highlights the need for more education and resources to increase HIV testing rates and to improve follow-up of an HCV-exposed infant.

Objective: To analyse the uptake of interventions known to reduce the risk of perinatal HIV transmission among Australian women with HIV infection (who knew their HIV status before delivery), and identify predictors of uptake., Design: Retrospective analysis of perinatal HIV surveillance data in Australia., Patients: Women reported as having HIV infection and having given birth to a child (1982-2005) were identified through three mechanisms: an informal network of clinicians (1982-1993); an active surveillance program through paediatricians (since 1993); and state health department reports of children born to women newly diagnosed with HIV (since 1995)., Main Outcome Measures: Uptake of interventions - avoidance of breastfeeding (after 1985), use of zidovudine during pregnancy (after 1994), and elective caesarean section (after 1999). Factors associated with uptake of these interventions were identified by univariate and multivariate analyses., Results: 367 live births were reported in 291 women with HIV infection. Among the subgroup diagnosed with HIV infection before delivery, 4/255 (1.6%) elected to breastfeed (post 1985), 44/185 (24%) did not receive zidovudine (after 1994), and 41/118 (35%) did not have an elective caesarean section (after 1999). In multivariate analysis, there were significant differences in uptake of zidovudine and elective caesarean section according to year of birth and state in which the birth took place., Conclusion: In Australia between 1982 and 2005, uptake of interventions to reduce mother-to-child transmission of HIV was high. There were significant differences associated with use of zidovudine and mode of delivery according to location of delivery and year of birth.

Objective: To investigate factors that influence the antenatal screening practice of obstetricians and identify barriers to the implementation of universal antenatal HIV screening., Design: A survey of all obstetricians registered with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists., Methods: A questionnaire was mailed to all obstetricians in Australia, followed by two reminders., Results: The overall response rate was 70% (817/1172) and of these 70% always offered an HIV test during pregnancy. Obstetricians offering the test were more likely to female or younger in age. Of respondents who always offered testing, 90% disagreed with only testing women with risk factors compared with only 34% of those who undertook a selective screening approach (adjusted odds ratio, 87.7; 95% confidence interval, 40-192; P = 0.001). Obstetricians who practiced selective screening were influenced by whether the woman had antenatal blood tests prior to her obstetric appointment or a previous negative HIV test. Obstetricians who practiced universal screening were more likely to be concerned about false-positive results. Many obstetricians, irrespective of their screening practice, agreed that many of the components of pretest counseling were inappropriate for the majority of women., Conclusions: A majority of obstetricians in Australia are offering all pregnant women an HIV test. Consideration should be given to tailoring pretest counseling requirements to the antenatal setting. Ongoing education regarding the limitations of selective screening and management of women with false-positive results is also highlighted by this study.

Australia is one of the few developed countries without routine antenatal HIV screening, despite having the resources to undertake such a screening program and the availability of antiretroviral therapy. National policy recommends that only women with identified risk factors should be offered testing; however, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists recommends that all pregnant women be offered HIV testing as part of their antenatal care. Knowledge of a woman's HIV status during pregnancy allows interventions to improve her health and reduce the risk of transmission of HIV to her child. A universal antenatal HIV screening program meets many of the Wilson and Jungner criteria for population-based screening programs. This should be considered in the current review of Australia's HIV testing policy.

Objective: To assess obstetricians' antenatal screening practice for blood-borne viruses (HIV, hepatitis B and C viruses [HBV and HCV]) and knowledge about management during labour and risk of transmission via breastfeeding for infected women after an educational intervention, Australia., Design: Cohort study, with surveys before and after an educational intervention., Setting and Participants: Survey 1 was mailed in 2002-2003 to all 767 Fellows registered with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), and Survey 2 was mailed in 2004 to the 743 of these Fellows who were still practising., Intervention: Multifaceted intervention with mail-out of survey results and a summary of recommended management, publication of two review articles in the RANZCOG journal, and an oral presentation at the RANZCOG annual scientific meeting., Main Outcome Measures: Self-reported frequency of antenatal screening for blood-borne viruses, change in practice based on a woman's infection status, and advice given about risk of virus transmission via breastfeeding in Survey 2, compared with Survey 1., Results: Survey 2 (response rate, 68%) found increases from the previous survey in the proportion of respondents reporting they always offered antenatal screening for HIV, from 51% to 59%, and for HCV, from 60% to 69% (P = 0.001 for both). For women with HIV infection, the proportion of respondents always recommending elective caesarean section increased from 37% to 49% (P = 0.001) and always avoiding rupture of membranes increased from 33% to 49% (P < 0.001). The proportion who reported advising (incorrectly) that breastfeeding is associated with increased risk of transmission to the infant decreased from 34% to 25% for HBV (P = 0.01) and from 47% to 39% for HCV (P = 0.03)., Conclusion: The frequency of antenatal testing for HIV and HCV is increasing in Australia. Knowledge about interventions to reduce mother-to-child transmission of HIV and knowledge of the risk of HBV and HCV transmission via breastfeeding improved after a relatively simple educational intervention.

It is estimated there are over 19 million women worldwide living with HIV infection. In Australia the total number of notified cases of HIV in women has been gradually increasing (the estimated number of women newly diagnosed with HIV infection was 78 in 2000 and 94 in 2001). Management of women in pregnancy and strategies to reduce perinatal transmission is critical, but differ significantly according to resource availability. The current review examines the best available scientific evidence and current guidelines for optimal management of HIV-infected women contemplating pregnancy in Australia.

Objective: To assess obstetricians' current antenatal screening practices for blood-borne viruses (hepatitis B, hepatitis C and HIV) and how they manage pregnant women infected with a blood-borne virus., Design and Participants: National cross-sectional survey conducted between September 2002 and January 2003. All obstetricians (n = 767) registered with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) were mailed a questionnaire assessing their antenatal screening practices and knowledge of management of women potentially infected with a blood-borne virus., Outcome Measures: Concordance of clinical practice with RANZCOG recommendations and current evidence-based guidelines., Results: 523 obstetricians (68% response rate) completed the questionnaire. Fifty-one per cent of respondents said they would always offer HIV screening and 60% would always offer HCV screening. For HIV-infected women, 36% of obstetricians would always recommend elective caesarean section and 33% would always avoid rupture of membranes. Despite a lack of evidence, 34% of obstetricians advise patients that the risk of HBV transmission is increased with breastfeeding, and 47% give the same advice about HCV transmission., Conclusion: There is some discordance between the RANZCOG antenatal screening recommendations for HCV and HIV and current practice. Knowledge about the management of HIV-infected women could be improved, and more obstetricians need to be aware that current evidence suggests there is no increased risk of transmission of HBV or HCV with breastfeeding.

The sensitivity of ultrasonography for detecting gallstones is high, but mishaps can occur. The three false positive cases we describe here illustrate problems which may be encountered in interpreting ultrasound images and in communication between the clinician, patient and ultrasonographer.

Objects: to determine whether children may grow out of recurrent acute tonsillitis., Methods: the parents of 100 children aged 2-14 on the elective waiting list for tonsillectomy were given a postal or telephone interview in November 1989., Results: data from the parents of 92 respondents showed the children had been on the waiting list for a mean of seven months. Ninety-two percent still suffered from sore throats and 79% had had at least one course of antibiotics within the last six months. There was no reduction in the frequency of sore throat or the number of courses of antibiotics in children who had waited longer., Conclusions: there was no justification for claiming that long waiting lists for tonsillectomy are frequently associated with resolution of recurrent acute tonsillitis.

The procedure used with the Du Pont aca for alpha-amylase (1,4,-alpha-D-glucan glucanohydrolase, EC 3.2.1.1) was evaluated in our laboratory and compared with the Roche Diagnostics "Amylochrome" and Perkin-Elmer Coleman 91 amylase assays. The within-run coefficients of variation (CV) for samples of fresh normal sera were: aca 5.8% and 4.3% on two different lots of reagent, Amylochrome 7.4%, and Coleman 91 3.3%. In sera with abnormally high amylase activity, the respective CV's were: aca, 1.2% and 0.8%; Amylochrome, 2.0%; and Coleman 91, 2.8%. Day-to-day precision studies on fresh and lyophilized normal and abnormal sera gave CV's in the following ranges: aca, 1.8% to 6.7%; Amylochrome, 3.0% to 5.2%; and Coleman 91, 4.5% to 5.9%. Results by the aca procedure were linearly related to activity to about 10-fold the upper limit of normal amylase activity. For serum, correlations were: r = 0.977 for aca vs. Coleman 91 and r = 0.974 for aca vs. Amylochrome. For urine they were: r = 0.978 for aca vs. Coleman 91 and r = 0.975 for aca vs. Amylochrome. Mean recovery from 53 supplemented samples was 98%. Icterus, hemolysis, and lipemia did not interfere with method correlation of aca vs. Coleman 91 or Amylochrome.

Habitual, loud snoring is common in the adult population, and may be the only symptom of the more serious Obstructive Sleep Apnoea syndrome. We report here our results of uvulo-palato-pharyngo-plasty (UPPP), with or without nasal surgery, for snoring. Quantitative grading of the severity of the snoring shows that all patients were cured of symptomatic snoring, but that snoring was not altogether abolished in all patients.

Diverticulectomy for pharyngeal pouch requires several days in hospital and carries a risk of postoperative fistula formation. Small to moderate sized pouches can be inverted easily. Experience with this technique has been encouraging and results are reported here. Large pouches of long standing probably should be excised rather than inverted.

We evaluated 16 claims made by Beckman Instruments, Inc. for its Enzyme Analyzer (System TR), under a rigid written protocol for the Product Evaluation Subcommittee of the Standards Committee of the College of American Pathologists. We found the following to be within the company's specifications: (a) accuracy and precision of the temperature control; (b) accuracy and precision of the sample and reagent pipets; (c) instrument precision, both within-run and between-day; (d) carry-over from a sample with activity greater than 1000 U/liter; (e) instrument-to-instrument variation; (f) analytical linearity; (g) analysis time; (h) correlation of the instrument-printed answer with the activity calculated manually from a strip-chart recorder; (i) precision of the instrument's built-in electronic "standard"; (j) effectiveness of the over-range indicators; and (k) correlation between results of these enzyme assay methods and those for kinetic methods used in our laboratory. The instrument performed well.