The 50 most-cited articles in The Medical Journal of Australia, 2019

Glaucoma is an irreversible progressive optic neuropathy, for which the major proven treatment is to lower the intraocular pressure (IOP). Five groups of IOP-lowering eye drops have varying mechanisms of action. Some drops, such as β-blockers and α-2 agonists, have potentially serious systemic side effects. Acetazolamide is the only available oral agent; it is effective at lowering IOP, but significant side effects relegate its use usually to refractory glaucoma. Two new eye drops, netarsudil and latanoprostene bunod, have recently been approved by the United States Food and Drug Administration. Both have novel IOP-lowering mechanisms and target the conventional aqueous outflow system. Selective laser trabeculoplasty is a gentle treatment that enhances conventional aqueous outflow. It may be used as an initial treatment, as a substitute for eye drops, or to delay glaucoma drainage surgery. Recent advancements in glaucoma surgery have seen an influx of minimally invasive glaucoma surgery devices, which are being used more frequently and earlier on in the treatment paradigm. As…

Frailty describes an individual's vulnerability to adverse health outcomes and is a useful construct that assists health professionals to understand the heterogeneity of the ageing population. While the pathophysiological pathways that lead to frailty are not well defined, an individual's sex appears to be a key factor influencing the ageing trajectory. Compared with age-matched men, women tend to have poorer health status (ie, they are more frail) but longer life expectancy (ie, they are more resilient). It seems likely that a combination of biological, behavioural and social factors underpin this male-female health-survival paradox. Randomised controlled trial data for frailty interventions in older adults are emerging, with multicomponent programs incorporating exercise and nutrition-based strategies showing promise. Pharmaceutical and other innovative therapeutic strategies for frailty are highly anticipated. Sex differences in the effectiveness of frailty interventions have not been addressed in the research literature to date. In the future, successful interventions may target…

Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change. Consequently, the effects of adolescent-onset mood and psychotic syndromes can have long term consequences. A key clinical challenge for youth mental health is to develop and test new systems that align with current evidence for comorbid presentations and underlying neurobiology, and are useful for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. Our highly personalised and measurement-based care model includes three core concepts: ▶ A multidimensional assessment and outcomes framework that includes: social and occupational function; self-harm, suicidal thoughts and behaviour; alcohol or other substance misuse; physical health; and illness trajectory. ▶ Clinical stage. ▶ Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on proposed pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). The model explicitly aims to prevent…

Diagnosis of deep vein thrombosis (DVT) requires a multifaceted approach that includes clinical assessment, evaluation of pre-test probability, and objective diagnostic testing. Common symptoms and signs of DVT are pain, swelling, erythema and dilated veins in the affected limb. The pre-test probability of DVT can be assessed using a clinical decision rule that stratifies DVT into "unlikely" or "likely". If DVT is "unlikely", refer for D-dimer test. If the D-dimer level is normal, DVT can be excluded; if the D-dimer level is increased, refer for compression ultrasound. If DVT is "likely", refer for compression ultrasound. When DVT is confirmed, anticoagulation is indicated to control symptoms, prevent progression and reduce the risk of post-thrombotic syndrome and pulmonary embolism. Anticoagulation may consist of a parenteral anticoagulant overlapped by warfarin or followed by a direct oral anticoagulant (DOAC) (dabigatran or edoxaban), or of a DOAC (apixaban or rivaroxaban) without initial parenteral therapy. DOACs are the preferred treatment for DVT because they are at least as…

OBJECTIVE: To estimate the prevalence of polypharmacy among Australians aged 70 years or more, 2006-2017. DESIGN, SETTING AND PARTICIPANTS: Analysis of a random 10% sample of Pharmaceutical Benefits Scheme (PBS) data for people aged 70 or more who were dispensed PBS-listed medicines between 1 January 2006 and 31 December 2017. MAIN OUTCOME MEASURES: Prevalence of continuous polypharmacy (five or more unique medicines dispensed during both 1 April - 30 June and 1 October - 31 December in a calendar year) among older Australians, and the estimated number of people affected in 2017; changes in prevalence of continuous polypharmacy among older concessional beneficiaries, 2006-2017. RESULTS: In 2017, 36.1% of older Australians were affected by continuous polypharmacy, or an estimated 935 240 people. Rates of polypharmacy were higher among women than men (36.6% v 35.4%) and were highest among those aged 80-84 years (43.9%) or 85-89 years (46.0%). The prevalence of polypharmacy among PBS concessional beneficiaries aged 70 or more increased by 9% during 2006-2017 (from 33.2% to 36.2%), but…

Erectile dysfunction (ED) is a common male sexual dysfunction associated with a reduced quality of life for patients and their partners. ED is associated with increasing age, depression, obesity, lack of exercise, diabetes mellitus, hypertension, dyslipidaemia, cardiovascular disease and lower urinary tract symptoms related to benign prostatic hyperplasia. The evaluation of men with ED requires a full medical and personally and culturally sensitive sexual history, a focused clinical examination, fasting glucose levels, a fasting lipid profile and, in select cases, a total testosterone level and a prostate-specific antigen test. Treatment of ED requires lifestyle modification, reduction of comorbid vascular risk factors, and treatment of organic or psychosexual dysfunction with either pharmacotherapy alone or in combination with psychosexual therapy. Between 60% and 65% of men with ED, including those with hypertension, diabetes mellitus, spinal cord injury and other comorbid medical conditions, can successfully complete intercourse in response to the phosphodiesterase type 5…

OBJECTIVES: To estimate the proportion of cancer diagnoses in Australia that might reasonably be attributed to overdiagnosis by comparing current and past lifetime risks of cancer. DESIGN, SETTING, AND PARTICIPANTS: Routinely collected Australian Institute of Health and Welfare national data were analysed to estimate recent (2012) and historical (1982) lifetime risks (adjusted for competing risk of death and changes in risk factors) of diagnoses with five cancers: prostate, breast, renal, thyroid cancers, and melanoma. MAIN OUTCOME MEASURE: Difference in lifetime risks of cancer diagnosis between 1982 and 2012, interpreted as probable overdiagnosis. RESULTS: For women, absolute lifetime risk increased by 3.4 percentage points for breast cancer (invasive cancers, 1.7 percentage points), 0.6 percentage point for renal cancer, 1.0 percentage point for thyroid cancer, and 5.1 percentage points for melanoma (invasive melanoma, 0.7 percentage point). An estimated 22% of breast cancers (invasive cancers, 13%), 58% of renal cancers, 73% of thyroid cancers, and 54% of melanomas (invasive…

INTRODUCTION: Paracetamol is a common agent taken in deliberate self-poisoning and in accidental overdose in adults and children. Paracetamol poisoning is the commonest cause of severe acute liver injury. Since the publication of the previous guidelines in 2015, several studies have changed practice. A working group of experts in the area, with representation from all Poisons Information Centres of Australia and New Zealand, were brought together to produce an updated evidence-based guidance. MAIN RECOMMENDATIONS (UNCHANGED FROM PREVIOUS GUIDELINES): The optimal management of most patients with paracetamol overdose is usually straightforward. Patients who present early should be given activated charcoal. Patients at risk of hepatotoxicity should receive intravenous acetylcysteine. The paracetamol nomogram is used to assess the need for treatment in acute immediate release paracetamol ingestions with a known time of ingestion. Cases that require different management include modified release paracetamol overdoses, large or massive overdoses, accidental liquid ingestion in children,…

INTRODUCTION: Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third most common cardiovascular disease and, globally, more than an estimated 10 million people have it yearly. It is a chronic and recurrent disease. The symptoms of VTE are non-specific and the diagnosis should actively be sought once considered. The mainstay of VTE treatment is anticoagulation, with few patients requiring additional intervention. A working group of experts in the area recently completed an evidence-based guideline for the diagnosis and management of DVT and PE on behalf of the Thrombosis and Haemostasis Society of Australia and New Zealand (www.thanz.org.au/resources/thanz-guidelines). MAIN RECOMMENDATIONS: The diagnosis of VTE should be established with imaging; it may be excluded by the use of clinical prediction rules combined with D-dimer testing. Proximal DVT or PE caused by a major surgery or trauma that is no longer present should be treated with anticoagulant therapy for 3 months. Proximal DVT or PE that is unprovoked or associated with a…

Genetic sequencing of the myeloma genome has not revealed a specific disease-determining genetic alteration. Multiple disease subclones exist at diagnosis and vary in clinical importance with time and drug sensitivity. New diagnostic criteria have identified indications for early introduction of therapy. Autologous stem cell transplantation remains an essential component of therapy in young and fit patients. The use of continual suppressive (maintenance) therapy has been established as an important component in therapy. Immune therapies and the harnessing of the innate immune system offer great promise for future treatments. Since 2005, quality of life, supportive therapies, and survival have dramatically improved over a decade of remarkable progress. The common manifestations of multiple myeloma, such as bone pain, fatigue and weight loss, may be non-specific and are often initially ignored or missed by patients and medical practitioners.

OBJECTIVE: To explore associations between frailty (Clinical Frailty Scale score of 5 or more) in very old patients in intensive care units (ICUs) and their clinical outcomes (mortality, discharge destination). DESIGN, SETTING AND PARTICIPANTS: Retrospective population cohort analysis of Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database data for all patients aged 80 years or more admitted to participating ICUs between 1 January 2017 and 31 December 2018. MAIN OUTCOME MEASURES: Primary outcome: in-hospital mortality; secondary outcomes: length of stay (hospital, ICU), re-admission to ICU during the same hospital admission, discharge destination (including new chronic care or nursing home admission). RESULTS: Frailty status data were available for 15 613 of 45 773 patients aged 80 years or more admitted to 178 ICUs (34%); 6203 of these patients (39.7%) were deemed frail. A smaller proportion of frail than non-frail patients were men (47% v 57%), the mean illness severity scores of frail patients were slightly higher than those of non-frail patients, and…

INTRODUCTION: Cholinesterase inhibitors (ChEIs) and memantine are medications used to treat the symptoms of specific types of dementia. Their benefits and harms can change over time, particularly during long term use. Therefore, appropriate use of ChEIs and memantine involves both prescribing these medications to individuals who are likely to benefit, and deprescribing (withdrawing) them from individuals when the risks outweigh the benefits. We recently developed an evidence-based clinical practice guideline for deprescribing ChEIs and memantine, using robust international guideline development processes. MAIN RECOMMENDATIONS: Our recommendations aim to assist clinicians to: identify individuals who may be suitable for a trial of deprescribing ChEIs and memantine (such as those who do not have an appropriate indication, those who have never experienced a benefit, those who appear to be no longer benefitting, and those who have severe or end-stage dementia); and taper treatment and monitor individuals during the deprescribing process. CHANGES IN MANAGEMENT AS A RESULT OF THE…

Cerebral palsy is a developmental disorder of movement and posture which is often associated with comorbidities. While there is currently a limited range of evidence-based treatments that change the underlying pathology of cerebral palsy, there are many areas in which health care professionals can change the natural history of cerebral palsy and improve participation and quality of life for children with this condition. Early identification has become of paramount importance in the management of cerebral palsy, and it is hoped that it will allow earlier access to cerebral palsy interventions that may improve the natural history of the condition. Common challenges in the management of cerebral palsy include spasticity and dystonia, management of pain, hip surveillance, sleep and feeding, swallowing and nutrition. The six Fs framework (function, family, fitness, fun, friends and future) provides a guide to developing shared goals with families in the management of cerebral palsy.

In Australia, there is limited use of primary health care data for research and for data linkage between health care settings. This puts Australia behind many developed countries. In addition, without use of primary health care data for research, knowledge about patients' journeys through the health care system is limited. There is growing momentum to establish "big data" repositories of primary care clinical data to enable data linkage, primary care and population health research, and quality assurance activities. However, little research has been conducted on the general public's and practitioners' concerns about secondary use of electronic health records in Australia. International studies have identified barriers to use of general practice patient records for research. These include legal, technical, ethical, social and resource-related issues. Examples include concerns about privacy protection, data security, data custodians and the motives for collecting data, as well as a lack of incentives for general practitioners to share data. Addressing barriers may help define good…

INTRODUCTION: The Australasian Society of Clinical Immunology and Allergy, the peak professional body for clinical immunology and allergy in Australia and New Zealand, develops and provides information on a wide range of immune-mediated disorders, including advice about infant feeding and allergy prevention for health professionals and families. Guidelines for infant feeding and early onset allergy prevention were published in 2016, with additional guidance published in 2017 and 2018, based on emerging evidence. MAIN RECOMMENDATIONS: When the infant is ready, at around 6 months, but not before 4 months, start to introduce a variety of solid foods. (This is not a strict window of introduction but rather a recommendation not to delay the introduction of solid foods beyond 12 months.) Introduce peanut and egg in the first year of life in all infants, regardless of their allergy risk factors. Hydrolysed (partially and extensively) formula is no longer recommended for the prevention of allergic disease. CHANGES IN MANAGEMENT A RESULT OF THE GUIDELINES: The guidelines specifically…

INTRODUCTION: Rising demand for gender-affirming hormone therapy mandates a need for more formalised care of transgender and gender diverse (TGD) individuals in Australia. Estimates suggest that 0.1-2.0% of the population are TGD, yet medical education in transgender health is lacking. We aim to provide general practitioners, physicians and other medical professionals with specific Australian recommendations for the hormonal and related management of adult TGD individuals. MAIN RECOMMENDATIONS: Hormonal therapy is effective at aligning physical characteristics with gender identity and in addition to respectful care, may improve mental health symptoms. Masculinising hormone therapy options include transdermal or intramuscular testosterone at standard doses. Feminising hormone therapy options include transdermal or oral estradiol. Additional anti-androgen therapy with cyproterone acetate or spironolactone is typically required. Treatment should be adjusted to clinical response. For biochemical monitoring, target estradiol and testosterone levels in the reference range of the affirmed…

OBJECTIVES: To assess the numbers of paracetamol overdose-related hospital admissions and deaths in Australia since 2007-08, and the overdose size of intentional paracetamol overdoses since 2004. DESIGN, SETTING: Retrospective analysis of data on paracetamol-related exposures, hospital admissions, and deaths from the Australian Institute of Health and Welfare National Hospital Morbidity Database (NHMD; 2007-08 to 2016-17), the New South Wales Poisons Information Centre (NSWPIC; 2004-2017), and the National Coronial Information System (NCIS; 2007-08 to 2016-17). PARTICIPANTS: People who took overdoses of paracetamol in single ingredient preparations. MAIN OUTCOME MEASURES: Annual numbers of reported paracetamol-related poisonings, hospital admissions, and deaths; number of tablets taken in overdoses. RESULTS: The NHMD included 95 668 admissions with paracetamol poisoning diagnoses (2007-08 to 2016-17); the annual number of cases increased by 44.3% during the study period (3.8% per year; 95% CI, 3.2-4.6%). Toxic liver disease was documented for 1816 of these patients; the annual…

The minimum requirements for total knee arthroplasty (TKA) are significant, prolonged symptoms with supporting clinical and radiological signs. Despite interest in screening tools, there is limited evidence for a specific symptom threshold that justifies surgery. Non-operative treatments including medications, exercise and weight loss are unlikely to reverse radiographic changes, but they may improve symptoms and delay the need for surgery. Many patient factors such as mental health and obesity affect both the level of symptomatic improvement after surgery and risks of surgery, but none have been identified as contraindications for the procedure as significant health gains can still be achieved. Although age and sex are associated with patient-reported outcomes and risk of revision, these factors cannot be used to restrict access to TKA, and age cut-offs are not recommended. Evidence regarding pre-operative optimisation of patients to improve post-operative TKA outcomes is limited by the few interventional trials available, particularly in the areas of patient expectation, diabetes,…

Impetigo, scabies, cellulitis and abscesses are common in Australian Aboriginal children. These conditions adversely affect wellbeing and are associated with serious long term sequelae, including invasive infection and post-infectious complications, such as acute post-streptococcal glomerulonephritis and acute rheumatic fever, which occurs at the highest documented rates in the world in remote Aboriginal communities. Observational research in remote communities in northern Australia has demonstrated a high concurrent burden of scabies and impetigo and their post-infectious complications. Few data are available for other Australian states, especially for urban Aboriginal children; however, nationwide hospital data indicate that the disparity between Aboriginal and non-Aboriginal children in skin infection prevalence also exists in urban settings. The Australian National Healthy Skin Guideline summarises evidence-based treatment of impetigo, scabies and fungal infections in high burden settings such as remote Aboriginal communities. It recommends systemic antibiotics for children with…

OBJECTIVE: To estimate rates of respiratory syncytial virus (RSV)-associated hospitalisation across the age spectrum, and to identify groups at particular risk of serious RSV-associated disease. DESIGN, SETTING AND PARTICIPANTS: Retrospective review of National Hospital Morbidity Database data for all RSV-associated hospitalisations in Australia, 2006-2015. MAIN OUTCOMES AND MEASURES: RSV-coded hospitalisation rates by age, sex, Indigenous status, jurisdiction, and seasonality (month and year); hospital length of stay; in-hospital deaths. RESULTS: During 2006-2015, there were 63 814 hospitalisations with an RSV-specific principal diagnostic code; 60 551 (94.9%) were of children under 5 years of age. The hospitalisation rate for children under 5 years was 418 per 100 000 population; for children under 6 months of age it was 2224 per 100 000 population; the highest rate was for infants aged 0-2 months (2778 per 100 000 population). RSV-coded hospitalisation rates were higher for adults aged 65 or more than for people aged 5-64 years (incidence rate ratio [IRR], 6.6; 95% CI, 6.2-7.1),…

2 Intensive care unit (ICU) costs per patient-day, by number of available ICU beds and occupancy

Project Synergy aims to test the potential of new and emerging technologies to enhance the quality of mental health care provided by traditional face-to-face services. Specifically, it seeks to ensure that consumers get the right care, first time (delivery of effective mental health care early in the course of illness). Using co-design with affected individuals, Project Synergy has built, implemented and evaluated an online platform to assist the assessment, feedback, management and monitoring of people with mental disorders. It also promotes the maintenance of wellbeing by collating health and social information from consumers, their supportive others and health professionals. This information is reported back openly to consumers and their service providers to promote genuine collaborative care. The online platform does not provide stand-alone medical or health advice, risk assessment, clinical diagnosis or treatment; instead, it supports users to decide what may be suitable care options. Using an iterative cycle of research and development, the first four studies of Project…

Vitamin D is made in the skin when exposed to sunlight, so deficiency is usually the result of low sunlight exposure (eg, in frail older people and in individuals who are veiled). Calcium and/or vitamin D supplements have been used for the prevention and treatment of osteoporosis. The major trials in community-dwelling individuals have not demonstrated fracture prevention with either calcium, vitamin D, or their combination, but the results of a large study in vitamin D-deficient nursing home residents indicated a reduced fracture incidence. Trials show that vitamin D increases bone density when winter 25-hydroxyvitamin D levels are below 25-30 nmol/L. However, assay expense and variability suggest that supplements are better targeted based on clinical status to frail older people and possibly to people with dark skin living at higher latitudes. A daily dose of 400-800 units (10-20 μg) is usually adequate. Parenteral antiresorptive drugs can cause hypocalcaemia in severe vitamin D deficiency (< 25 nmol/L), which should therefore be corrected before treatment. Clinical trials have…

Radiological evidence of inflammation, using computed tomography (CT), is needed to diagnose the first occurrence of diverticulitis. CT is also warranted when the severity of symptoms suggests that perforation or abscesses have occurred. Diverticulitis is classified as complicated or uncomplicated based on CT scan, severity of symptoms and patient history; this classification is used to direct management. Outpatient treatment is recommended in afebrile, clinically stable patients with uncomplicated diverticulitis. For patients with uncomplicated diverticulitis, antibiotics have no proven benefit in reducing the duration of the disease or preventing recurrence, and should only be used selectively. For complicated diverticulitis, non-operative management, including bowel rest and intravenous antibiotics, is indicated for small abscesses; larger abscesses of 3-5 cm should be drained percutaneously. Patients with peritonitis and sepsis should receive fluid resuscitation, rapid antibiotic administration and urgent surgery. Surgical intervention with either Hartmann procedure or primary…

New digital health services and technologies are transforming how health care is provided and experienced in Australia The health care industry is one of the last industries to be disrupted by digital technologies. It arguably has the most to gain, particularly from timely, accurate communication and clinical improvements, especially medication safety. In 2013, a literature review on medication safety in Australia1 suggested that the potential cost of medication-related hospital admissions in 2011–12 was about $1.2 billion. The landscape is changing. Over the past two decades, Australia has witnessed digital health services and technologies transform the way in which health care is provided and experienced (Box). These changes have been prefaced with a focus on clinical safety, quality improvement, privacy and confidentiality, and are delivering significant health system efficiencies and clinical benefits. This article reflects on that journey. In the early 1990s, each state and territory in Australia progressively updated its poisons regulations to allow for computer-generated…

ten peer-reviewed journals in Australia,* according to a web-based search in December

OBJECTIVES: To generate Australian general population reference values for the EORTC Quality of Life Questionnaire for cancer patients (QLQ-C30); to compare Australian values with published EORTC general population reference values, and to explore associations between socio-demographic and health characteristics and QLQ-C30 subscale scores. DESIGN: Analysis of responses to cross-sectional, online survey (QLQ-C30), March 2015 - February 2016, and supplementary health-related and socio-demographic questions. SETTING, PARTICIPANTS: 1979 people quota-sampled from a national online survey panel to be representative of the Australian general population by age and sex. MAIN OUTCOME MEASURES: Mean QLQ-C30 subscale scores, adjusted for socio-demographic characteristics and comorbid conditions, by sex and age group. RESULTS: Data for 1821 participants were analysed (92% completion rate); 924 (50.7%) were women. Higher psychological distress was associated with worse outcomes on all QLQ-C30 subscales. Better self-reported general health was associated with better global quality of life and…

Awareness and use of e-cigarettes is increasing in Australia.1 The thousands of available e-liquids contain various excipients, nicotine, flavourings, and other additives. There is little to no regulation of their manufacture, and potentially dangerous ingredients and incorrect nicotine levels have been identified.2 Of particular concern is the frequency with which nicotine is detected in e-liquids labelled "nicotine-free".2 E-liquids containing nicotine cannot legally be sold in Australia,3 but inaccurate labelling means that users may unwittingly inhale this addictive substance, or retailers may sell incorrectly labelled nicotine-containing e-liquids to willing customers. The aim of our investigation was to assess the chemical composition of a range of e-liquids available in Australia, focusing on nicotine and other potentially harmful compounds. Formal ethics approval was not required for this study. We purchased ten "nicotine-free" e-liquids of a variety of brands and flavours, online and over the counter from Australian suppliers. None disclosed ingredient information beyond…

OBJECTIVES: To determine the validity, sensitivity, specificity and acceptability of the culturally adapted nine-item Patient Health Questionnaire (aPHQ-9) as a screening tool for depression in Aboriginal and Torres Strait Islander people. DESIGN: Prospective observational validation study, 25 March 2015 - 2 November 2016. SETTING, PARTICIPANTS: 500 adults (18 years or older) who identified as Aboriginal or Torres Strait Islander people and attended one of ten primary health care services or service events in urban, rural and remote Australia that predominantly serve Indigenous Australians, and were able to communicate sufficiently to respond to questionnaire and interview questions. MAIN OUTCOME MEASURES: Criterion validity of the aPHQ-9, with the depression module of the Mini-International Neuropsychiatric Interview (MINI) 6.0.0 as the criterion standard. RESULTS: 108 of 500 participants (22%; 95% CI, 18-25%) had a current episode of major depression according to the MINI criterion. The sensitivity of the aPHQ-9 algorithm for diagnosing a current major depressive episode was 54%…

Medical Journal of AustraliaVolume 210, Issue 5 p. 202-203.e1 Perspectives "Better health in the bush": why we urgently need a national rural and remote health strategy John Wakerman, Corresponding Author John Wakerman john.wakerman@flinders.edu.au Flinders Northern Territory, Flinders University, Darwin, NTJohn.Wakerman@flinders.edu.auSearch for more papers by this authorJohn S Humphreys, John S Humphreys School of Rural Health, Monash University, Bendigo, VICSearch for more papers by this author John Wakerman, Corresponding Author John Wakerman john.wakerman@flinders.edu.au Flinders Northern Territory, Flinders University, Darwin, NTJohn.Wakerman@flinders.edu.auSearch for more papers by this authorJohn S Humphreys, John S Humphreys School of Rural Health, Monash University, Bendigo, VICSearch for more papers by this author First published: 24 February 2019 https://doi.org/10.5694/mja2.50041Citations: 28Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our…

The MJA-Lancet Countdown on health and climate change was established in 2017 and produced its first Australian national assessment in 2018. It examined 41 indicators across five broad domains: climate change impacts, exposures and vulnerability; adaptation, planning and resilience for health; mitigation actions and health co-benefits; economics and finance; and public and political engagement. It found that, overall, Australia is vulnerable to the impacts of climate change on health, and that policy inaction in this regard threatens Australian lives. In this report we present the 2019 update. We track progress on health and climate change in Australia across the same five broad domains and many of the same indicators as in 2018. A number of new indicators are introduced this year, including one focused on wildfire exposure, and another on engagement in health and climate change in the corporate sector. Several of the previously reported indicators are not included this year, either due to their discontinuation by the parent project, the Lancet Countdown, or because insufficient new…

Bacteriophage (phage) therapy is re-emerging a century after it began. Activity against antibiotic-resistant pathogens and a lack of serious side effects make phage therapy an attractive treatment option in refractory bacterial infections. Phages are highly specific for their bacterial targets, but the relationship between in vitro activity and in vivo efficacy remains to be rigorously evaluated. Pharmacokinetic and pharmacodynamic principles of phage therapy are generally based on the classic predator-prey relationship, but numerous other factors contribute to phage clearance and optimal dosing strategies remain unclear. Combinations of fully characterised, exclusively lytic phages prepared under good manufacturing practice are limited in their availability. Safety has been demonstrated but randomised controlled trials are needed to evaluate efficacy.

OBJECTIVES: To compare the effects on perinatal maternal and neonatal outcomes of intravenous and oral iron therapy as first-line treatment of iron deficiency anaemia (IDA) in pregnant women. STUDY DESIGN: A meta-analysis, applying fixed and random effects models, of randomised controlled trials (RCTs) that compared the effects of intravenous and oral iron therapy for pregnant women with IDA. DATA SOURCES: MEDLINE, EMBASE, Scopus, Cochrane Register of Controlled Trials, Web of Science; bibliographies of identified articles. DATA SYNTHESIS: Fifteen eligible studies with a total of 1938 participants were identified. Each was at high risk of bias in at least one domain; ten were undertaken in low or middle income countries. Evidence (from nine RCTs) that intravenous iron was superior to oral iron in reducing the need for blood transfusion at delivery was low quality (Peto odds ratio, 0.19 [95% CI, 0.05-0.78]; number needed to treat, 95 [95% CI, 81-348]). Evidence that intravenous iron was superior to oral iron in increasing neonatal birthweight (eight RCTs: mean difference, 58 g; 95%…

To the Editor: Infective endocarditis with Staphylococcus aureus is associated with a high mortality despite optimal antibiotic therapy.1 The synergy between bacteriophages and antibiotics has been shown in vitro and in animal studies,2 and bacteriophages have demonstrated their value in severe bacterial infections.3 AB-SA01 (AmpliPhi Biosciences) is a bacterial DNA-free and protein-free highly purified preparation of three obligately lytic Myoviridae, each at 109 plaque-forming units per dose.4 This preparation has been recently used successfully for staphylococcal sinusitis by local irrigation.5 A protocol was established for bacteriophage therapy as an adjunct to standard care of severe staphylococcal infections under the auspices of the Therapeutic Goods Administration Special Access Scheme. Here, we report the first intravenous use of AB-SA01 in a case of severe staphylococcal sepsis with prosthetic valve endocarditis. A 65-year-old man with a 30-year-old mechanical aortic valve presented with a week of malaise, severe exertional dyspnoea, and central pleuritic chest pain. He…

OBJECTIVE: To examine the utility of apnoea screening questionnaires, alone and in combination with the Epworth sleepiness scale (ESS), for detecting obstructive sleep apnoea (OSA) in primary care. DESIGN, SETTING: Prospective validation study in an Australian general population cohort. PARTICIPANTS: 424 of 772 randomly invited Tasmanian Longitudinal Health Study, 6th decade follow-up participants with OSA symptoms (mean age, 52.9 years; SD, 0.9 year) who completed OSA screening questionnaires and underwent type 4 sleep studies. MAIN OUTCOME MEASURES: Clinically relevant OSA, defined as moderate to severe OSA (15 or more oxygen desaturation events/hour), or mild OSA (5-14 events/hour) and excessive daytime sleepiness (ESS ≥ 8); diagnostic test properties of the Berlin (BQ), STOP-Bang and OSA-50 questionnaires, alone or combined with an ESS ≥ 8. RESULTS: STOP-Bang and OSA-50 correctly identified most participants with clinically relevant OSA (sensitivity, 81% and 86% respectively), but with poor specificity (36% and 21% respectively); the specificity (59%) and sensitivity of the BQ…

OBJECTIVES: To describe changes in childhood cancer incidence in Australia, 1983-2015, and to estimate projected incidence to 2035. DESIGN, SETTING: Population-based study; analysis of Australian Childhood Cancer Registry data for the 20 547 children under 15 years of age diagnosed with cancer in Australia between 1983 and 2015. MAIN OUTCOME MEASURES: Incidence rate changes during 1983-2015 were assessed by joinpoint regression, with rates age-standardised to the 2001 Australian standard population. Incidence projections to 2035 were estimated by age-period-cohort modelling. RESULTS: The overall age-standardised incidence rate of childhood cancer increased by 34% between 1983 and 2015, increasing by 1.2% (95% CI, +0.5% to +1.9%) per annum between 2005 and 2015. During 2011-2015, the mean annual number of children diagnosed with cancer in Australia was 770, an incidence rate of 174 cases (95% CI, 169-180 cases) per million children per year. The incidence of hepatoblastoma (annual percentage change [APC], +2.3%; 95% CI, +0.8% to +3.8%), Burkitt lymphoma (APC, +1.6%; 95% CI, +0.4% to…

OBJECTIVES: To report human papillomavirus (HPV) testing patterns and rates of oncogenic HPV-positivity for specimens submitted during the first 6 months after the National Cervical Screening Program switched from cytology- to primary HPV-based screening. DESIGN, PARTICIPANTS: Retrospective cross-sectional review of 195 606 specimens submitted for HPV testing, 1 December 2017 - 31 May 2018. SETTING: Large community-based general pathology laboratory in metropolitan Sydney. MAIN OUTCOME MEASURES: Prevalence of oncogenic HPV types (all, HPV16/18, non-HPV16/18) by reason for HPV test (primary screening, non-screening); for oncogenic HPV-positive women in the age band recommended for primary HPV screening (25-74 years), prevalence of cytologic abnormality and rates of 12-month follow-up and colposcopy recommendations. RESULTS: 195 606 samples were received: 157 700 (80.6%) for primary screening, 37 906 (19.4%) for non-screening tests. Oncogenic HPV was detected in 8.1% of screening tests (95% CI, 7.9-8.2%) and 20.9% of non-screening tests (95% CI, 20.5-21.3%); 35.5% (95% CI, 34.7-36.4%)…

Intersectoral collaboration is needed to engage communities and design effective culturally and age-appropriate interventions The gap between the health of Aboriginal and Torres Strait Islander and non-Indigenous Australians is well documented, with many policies and programs currently working towards improving outcomes. Despite these efforts, life expectancy is 10–11 years less than that of non-Indigenous Australians,1 and 65% of deaths occur before 65 years of age, compared with 19% in the non-Indigenous population.1 Cardiovascular and metabolic diseases are responsible for most of the gap in life expectancy and are associated with higher hospitalisation and mortality rates.1 In 2013, hospitalisation rates for cardiovascular disease were 1.6–2.5 times higher in Indigenous people depending on age, and Indigenous adults are six times as likely to die from diabetes as non-Indigenous Australians.1 Indigenous adolescents with type 2 diabetes are over ten times more likely to be hospitalised than non-Indigenous adolescents.2 While we acknowledge that hospitalisations are a poor…

Machine learning (ML), a subdiscipline of artificial intelligence, encompasses a family of computerised (machine) methods that identify (learn) patterns in large (training) datasets not detectable to humans (Box 1). Identified patterns are then encoded in a computer model or algorithm which is then tested and validated on new data. Three basic ML types exist (Box 2), with supervised and reinforcement learning being used most frequently.

OBJECTIVES: To examine associations between being the subject of child protection reports in early childhood and diagnoses of mental disorders during middle childhood, by level of service response. DESIGN, SETTING, PARTICIPANTS: Retrospective analysis of linked New South Wales administrative data, 2001-2016, for a population cohort of children (mean age in 2016, 13.2 years; SD, 0.37 years) enrolled in the longitudinal NSW Child Development Study (NSW-CDS), wave 2 linkage. MAIN OUTCOME MEASURES: Associations between being the subject of a child protection report (any, and by level of child protection response) during early childhood (birth to 6 years of age) and diagnoses of mental disorders during middle childhood (6-14 years). RESULTS: 13 796 of 74 462 children in the NSW-CDS (18.5%) had been the subjects of reports to child protection services during early childhood: 1148 children had been placed in out-of-home care at least once, and 1680 had been the subjects of substantiated risk-of-significant-harm reports but were not placed in care, while 9161 had non-substantiated reports,…

Parkinson disease (PD) is a complex neurodegenerative disorder that can present heterogeneously with a combination of motor and non-motor symptoms. α-synuclein, a neuronal protein, can undergo aberrant conformational change resulting in the intra-neuronal accumulation of toxic oligomers that form Lewy bodies, the pathological hallmark of PD. There is evidence that pathological α-synuclein exhibits prion-like behaviour in its mode of transmission through the nervous system. The choice of initial dopaminergic treatments should be individually tailored but long term outcomes appear to be equivalent. There is level A evidence supporting the benefit of three different device-assisted therapies in treating troublesome motor fluctuations and dyskinesias. Stem cell transplantation as currently being trialled is predominantly a symptomatic therapy targeting only limited regions of the brain affected by PD, and will need to be proven to be not only as effective but as safe as currently available device-assisted therapies. New modes of treatment including active immunisation against oligomeric…

OBJECTIVES: To evaluate the performance of the 2013 Pooled Cohort Risk Equation (PCE-ASCVD) for predicting cardiovascular disease (CVD) in an Australian population; to compare this performance with that of three frequently used Framingham-based CVD risk prediction models. DESIGN: Prospective national population-based cohort study. SETTING: 42 randomly selected urban and non-urban areas in six Australian states and the Northern Territory. PARTICIPANTS: 5453 adults aged 40-74 years enrolled in the Australian Diabetes, Obesity and Lifestyle study and followed until November 2011. We excluded participants who had CVD at baseline or for whom data required for risk model calculations were missing. MAIN OUTCOME MEASURES: Predicted and observed 10-year CVD risks (adjusted for treatment drop-in); performance (calibration and discrimination) of four CVD risk prediction models: 1991 Framingham, 2008 Framingham, 2008 office-based Framingham, 2013 PCE-ASCVD. RESULTS: The performance of the 2013 PCE-ASCVD model was slightly better than 1991 Framingham, and each was better the two 2008 Framingham…

There are worrying reports of escalating numbers of emergency department presentations by riders and pedestrians with injuries caused by electric scooters (e‐scooters). In Brisbane, injuries involving shared e‐scooters were monitored for about 2 months in early 2019; of the 109 patients for whom data were available, 12 had minor head injuries, three major head injuries, 23 upper limb fractures, and seven lower limb fractures. Not wearing helmets, travelling at more than 30 km/h, and alcohol consumption were identified as significant factors in e‐scooter accidents...

OBJECTIVES: To assess variations by time of year and hospital in the uptake of influenza and pertussis vaccinations by pregnant women in Victoria; to identify factors associated with vaccination uptake. DESIGN, SETTING: Retrospective analysis of data in the Victorian Perinatal Data Collection (VPDC), a population surveillance system for obstetric conditions, procedures, and pregnancy and birth outcomes. PARTICIPANTS: Women whose pregnancies ended in a live or stillbirth during July 2015 - June 2017. MAIN OUTCOME MEASURES: Influenza and pertussis vaccinations during pregnancy. RESULTS: 153 980 pregnancies in 67 hospitals ended during July 2015 - June 2017; 59 968 pregnant women (39.0%) were vaccinated against influenza and 98 583 (64.0%) against pertussis. Coverage varied by pregnancy end date, rising for influenza during winter and spring, but for pertussis rising continuously across the two years from 37.5% to 82.2%. Differences between hospitals in coverage were marked. Factors associated with vaccination included greater maternal age, primigravidity, early antenatal care, and…

OBJECTIVE: To determine whether rapid polymerase chain reaction (PCR) testing for influenza and respiratory syncytial viruses (RSV) in emergency departments (EDs) is associated with better patient and laboratory outcomes than standard multiplex PCR testing. DESIGN, SETTING: A before-and-after study in four metropolitan EDs in New South Wales. PARTICIPANTS: 1491 consecutive patients tested by standard multiplex PCR during July-December 2016, and 2250 tested by rapid PCR during July-December 2017. MAIN OUTCOME MEASURES: Hospital admissions; ED length of stay (LOS); test turnaround time; patient receiving test result before leaving the ED; ordering of other laboratory tests. RESULTS: Compared with those tested by standard PCR, fewer patients tested by rapid PCR were admitted to hospital (73.3% v 77.7%; P < 0.001) and more received their test results before leaving the ED (67.4% v 1.3%; P < 0.001); the median test turnaround time was also shorter (2.4 h [IQR, 1.6-3.9 h] v 26.7 h [IQR, 21.2-37.8 h]). The proportion of patients admitted to hospital was also lower in the rapid PCR group…

■ Metformin is recommended as first-line therapy for type 2 diabetes because of its safety, low cost and potential cardiovascular benefits. ■ The use of metformin was previously restricted in people with chronic kidney disease (CKD) — a condition that commonly coexists with diabetes — due to concerns over drug accumulation and metformin-associated lactic acidosis. ■ There are limited data from observational studies and small randomised controlled trials to suggest that metformin, independent of its antihyperglycaemic effects, may be associated with lower risk of myocardial infarction, stroke and all-cause mortality in people with type 2 diabetes and CKD. ■ Research into the risk of metformin-associated lactic acidosis in CKD has previously been limited and conflicting, resulting in significant variation across international guidelines on the safe prescribing and dosing of metformin at different stages of renal impairment. ■ Present-day large scale cohort studies now provide supporting evidence for the safe use of metformin in mild to moderate renal impairment (estimated glomerular…

OBJECTIVES: To evaluate the health impact and cost-effectiveness of systematic testing for Lynch syndrome (LS) in people with incident colorectal cancer (CRC) in Australia. DESIGN, SETTING, PARTICIPANTS: We investigated the impact of LS testing strategies in a micro-simulation model (Policy1-Lynch), explicitly modelling the cost of testing all patients diagnosed with incident CRC during 2017, with detailed modelling of outcomes for patients identified as LS carriers (probands) and their at-risk relatives throughout their lifetimes. For people with confirmed LS, we modelled ongoing colonoscopic surveillance. MAIN OUTCOME MEASURES: Cost-effectiveness of six universal tumour testing strategies (testing for DNA mismatch repair deficiencies) and of universal germline gene panel testing of patients with incident CRC; impact on cost-effectiveness of restricting testing by age at CRC diagnosis (all ages, under 50/60/70 years) and of colonoscopic surveillance interval (one, two years). RESULTS: The cost-effectiveness ratio of universal tumour testing strategies (annual colonoscopic…