The 50 most-cited articles in The Medical Journal of Australia, 2022

Early detection and management of prostate cancer has evolved over the past decade, with a focus now on harm minimisation and reducing overdiagnosis and overtreatment, given the proven improvements in survival from randomised controlled trials. Multiparametric magnetic resonance imaging (mpMRI) is now an important aspect of the diagnostic pathway in prostate cancer, improving the detection of clinically significant prostate cancer, enabling accurate localisation of appropriate sites to biopsy, and reducing unnecessary biopsies in most patients with normal magnetic resonance imaging scans. Biopsies are now performed transperineally, substantially reducing the risk of post-procedure sepsis. Australian-led research has shown that prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) has superior accuracy in the staging of prostate cancer than conventional imaging (CT and whole-body bone scan). Localised prostate cancer that is low risk (International Society for Urological Pathology [ISUP] grade 1, Gleason score 3 + 3 = 6; and ISUP grade…

OBJECTIVE: To assess the identification of primary aldosteronism (PA) in newly diagnosed, treatment-naïve patients with hypertension by screening in primary care. DESIGN: Prospective study. SETTING: General practices in the South Eastern Melbourne Primary Health Network with at least three general practitioners and general practices elsewhere in Victoria that had referred patients to the Endocrine Hypertension Clinic at Monash Health, 2017-2020. PARTICIPANTS: Adults (18-80 years) with newly diagnosed hypertension (measurements of systolic blood pressure > 140 mmHg or diastolic blood pressure > 90 mmHg on at least two occasions) and not taking antihypertensive medications were screened for PA by assessing their aldosterone-to-renin ratio (ARR). Participants with two ARR values exceeding 70 pmol/mU underwent saline suppression testing at the Endocrine Hypertension Service (Monash Health) to confirm the diagnosis of PA. MAIN OUTCOME MEASURES: Prevalence of PA (number of patients with confirmed PA divided by number screened). RESULTS: Sixty-two of 247 screened participants had elevated…

Atopic dermatitis (atopic eczema) is the most common inflammatory skin disease and has a significant burden on the quality of life of patients, families and caregivers. Its pathogenesis is a complex interplay between genetics and environment, involving impaired skin barrier function, immune dysregulation primarily involving the Th2 inflammatory pathway, itch, and skin microbiome. Restoration of skin barrier integrity with regular emollients and prompt topical anti-inflammatory therapies are mainstays of treatment. Systemic therapy is considered for moderate to severe disease. New understanding of inflammatory pathways and developments in targeted systemic immunotherapies have significantly advanced atopic dermatitis management. Dupilumab is a safe and effective treatment that is now available in Australia. Other promising agents for atopic dermatitis include Janus kinase, interleukin (IL)-13 and IL-31 inhibitors.

Low back pain (LBP) is common and a leading cause of disability and lost productivity worldwide. Acute LBP is frequently self-resolving, but recurrence is common, and a significant proportion of patients will develop chronic pain. This transition is perpetuated by anatomical, biological, psychological and social factors. Chronic LBP should be managed with a holistic biopsychosocial approach of generally non-surgical measures. Spinal surgery has a role in alleviating radicular pain and disability resulting from neural compression, or where back pain relates to cancer, infection, or gross instability. Spinal surgery for all other forms of back pain is unsupported by clinical data, and the broader evidence base for spinal surgery in the management of LBP is poor and suggests it is ineffective. Emerging areas of interest include selection of a minority of patients who may benefit from surgery based on spinal sagittal alignment and/or nuclear medicine scans, but an evidence base is absent. Spinal surgery for back pain has increased substantially over recent decades, and…

▪In this narrative review, we summarise the vast and burgeoning research on the potential and established indirect impacts on children of the COVID-19 pandemic. We used a community child health lens to organise our findings and to consider how Australia might best respond to the needs of children (aged 0-12 years). ▪We synthesised the literature on previous pandemics, epidemics and natural disasters, and the current COVID-19 pandemic. We found clear evidence of adverse impacts of the COVID-19 pandemic on children that either repeated or extended the findings from previous pandemics. ▪We identified 11 impact areas, under three broad categories: child-level factors (poorer mental health, poorer child health and development, poorer academic achievement); family-level factors that affect children (poorer parent mental health, reduced family income and job losses, increased household stress, increased abuse and neglect, poorer maternal and newborn health); and service-level factors that affect children (school closures, reduced access to health care, increased use of technology for…

INTRODUCTION: The prevalence of hepatitis B virus (HBV) infection in Australia is nearly 1%. In certain well defined groups the prevalence is far greater, yet an estimated 27% of people living with HBV infection remain undiagnosed. Appropriate screening improves detection, increases opportunity for treatment, and ultimately reduces the significant morbidity and mortality associated with the development of liver fibrosis and hepatocellular carcinoma (HCC). MAIN RECOMMENDATIONS: This statement highlights important aspects of HBV infection management in Australia. There have been recent changes in nomenclature and understanding of natural history, as well as a newly defined upper limit of normal for liver tests that determine phase classification and threshold for antiviral treatment. As the main burden of hepatitis B in Australia is within migrant and Indigenous communities, early identification and management of people living with hepatitis B is essential to prevent adverse outcomes including liver cancer and cirrhosis. CHANGE IN MANAGEMENT AS A RESULT OF THIS GUIDELINE: These…

OBJECTIVE: To examine associations between extended medical graduates' rural clinical school (RCS) experience and geographic origins with practising in rural communities five and eight years after graduation. DESIGN, PARTICIPANTS: Cohort study of 2011 domestic medical graduates from ten Australian medical schools with rural clinical or regional medical schools. MAIN OUTCOME MEASURES: Practice location types eight years after graduation (2019/2020) as recorded by the Australian Health Practitioner Regulation Agency, classified as rural or metropolitan according to the 2015 Modified Monash Model; changes in practice location type between postgraduate years 5 (2016/2017) and 8 (2019/2020). RESULTS: Data were available for 1321 graduates from ten universities; 696 were women (52.7%), 259 had rural backgrounds (19.6%), and 413 had extended RCS experience (31.3%). Eight years after graduation, rural origin graduates with extended RCS experience were more likely than metropolitan origin graduates without this experience to practise in regional (relative risk [RR], 3.6; 95% CI, 1.8-7.1) or…

Patient activation is a behavioural concept and is at the heart of personalised care. It is defined as an individual's knowledge, skill and confidence for managing their health and health care. Evidence indicates that patient activation scores can predict health behaviour and are closely linked to various clinical outcomes: reduced unnecessary emergency department visits, hospital admissions and re-admissions. Patients with lower activation levels (25-40% of the population) are less likely to adopt healthy behaviour, and more likely to have poorer clinical outcomes and higher rates of hospitalisation. Effective interventions can improve a patient's activation level, and positive change in activation equates to positive change in self-care behaviour. But to improve patient activation, we must first measure it using a robust evidence-based tool such as the Patient Activation Measure (PAM) survey. Armed with the patient's PAM score, providers can tailor their care and help patients achieve better self-care, which can improve outcomes of care and reduce unnecessary health care…

INTRODUCTION: This consensus statement of Australian clinicians provides new recommendations for the pharmacological management of heart failure based on studies reported since the publication of the 2018 Australian heart failure guidelines. MAIN RECOMMENDATIONS: ▪Use of sodium-glucose cotransporter 2 (SGLT2) inhibitors to prevent hospitalisation for heart failure in type 2 diabetes mellitus can be extended to patients with multiple cardiovascular risk factors, albuminuric chronic kidney disease, or atherosclerotic cardiovascular disease. ▪New evidence supports the use of a mineralocorticoid receptor antagonist (finerenone) to prevent heart failure in type 2 diabetes mellitus associated with albuminuric chronic kidney disease. ▪In addition to renin angiotensin system inhibitors (angiotensin receptor neprilysin inhibitor preferred), beta blockers and mineralocorticoid receptor antagonists, an SGLT2 inhibitor (dapagliflozin or empagliflozin) is recommended in all patients with heart failure with reduced left ventricular ejection fraction (LVEF ≤ 40%) (HFrEF). Lower quality evidence…

OBJECTIVE: To compare the demographic and clinical features, management, and outcomes for patients admitted with COVID-19 to intensive care units (ICUs) during the first, second, and third waves of the pandemic in Australia. DESIGN, SETTING, AND PARTICIPANTS: People aged 16 years or more admitted with polymerase chain reaction-confirmed COVID-19 to the 78 Australian ICUs participating in the Short Period Incidence Study of Severe Acute Respiratory Infection (SPRINT-SARI) Australia project during the first (27 February - 30 June 2020), second (1 July 2020 - 25 June 2021), and third COVID-19 waves (26 June - 1 November 2021). MAIN OUTCOME MEASURES: Primary outcome: in-hospital mortality. SECONDARY OUTCOMES: ICU mortality; ICU and hospital lengths of stay; supportive and disease-specific therapies. RESULTS: 2493 people (1535 men, 62%) were admitted to 59 ICUs: 214 during the first (9%), 296 during the second (12%), and 1983 during the third wave (80%). The median age was 64 (IQR, 54-72) years during the first wave, 58 (IQR, 49-68) years during the second, and 54 (IQR, 41-65) years…

OBJECTIVE: To compare fall incidence, and visual acuity and refractive status, before surgery and after first and second eye cataract surgery. DESIGN, SETTING: Prospective observational study in eight tertiary referral ophthalmology clinics in public hospitals in Sydney, Melbourne, and Perth. PARTICIPANTS: People aged 65 years or more referred for bilateral age-related cataract surgery during 2013-16, followed for maximum of 24 months after study entry or until six months after second eye surgery, whichever was shorter. MAIN OUTCOME MEASURES: Primary outcome: age- and sex-adjusted incidence of falls. SECONDARY OUTCOMES: visual acuity and refractive error. RESULTS: The mean age of the 409 included participants was 75.4 years (SD, 5.4 years); 220 were women (54%). Age- and sex-adjusted fall incidence prior to surgery was 1.17 (95% CI, 0.95-1.43) per year, 0.81 (95% CI, 0.63-1.04) per year after first eye surgery, and 0.41 (95% CI, 0.29-0.57) per year after second eye surgery. For the 118 participants who underwent second eye surgery and participated in all follow-up visits, age- and…

The MJA-Lancet Countdown on health and climate change in Australia was established in 2017 and produced its first national assessment in 2018 and annual updates in 2019, 2020 and 2021. It examines 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. In this, the fifth year of the MJA-Lancet Countdown, we track progress on an extensive suite of indicators across these five domains, accessing and presenting the latest data and further refining and developing our analyses. Within just two years, Australia has experienced two unprecedented national catastrophes - the 2019-2020 summer heatwaves and bushfires and the 2021-2022 torrential rains and flooding. Such events are costing lives and displacing tens of thousands of people. Further, our analysis shows that there are clear signs that Australia's health emergency management capacity substantially decreased in 2021. We find some signs of progress with respect to…

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a treatable and preventable disease characterised by persistent respiratory symptoms and chronic airflow limitation on spirometry. COPD is highly prevalent and is associated with exacerbations and comorbid conditions. "COPD-X" provides quarterly updates in COPD care and is published by the Lung Foundation Australia and the Thoracic Society of Australia and New Zealand. MAIN RECOMMENDATIONS: The COPD-X guidelines (version 2.65) encompass 26 recommendations addressing: case finding and confirming diagnosis; optimising function; preventing deterioration; developing a plan of care; and managing an exacerbation. CHANGES IN MANAGEMENT AS A RESULT OF THESE GUIDELINES: Both non-pharmacological and pharmacological strategies are included within these recommendations, reflecting the importance of a holistic approach to clinical care for people living with COPD to delay disease progression, optimise quality of life and ensure best practice care in the community and hospital settings when managing exacerbations. Several of the new…

Gender-based violence includes intimate partner violence, sexual violence and other harmful acts directed at people based on their gender. It is common in Australia and causes great ill health, especially for women victims/survivors, with Indigenous women particularly affected. Health services are an opportune place for early intervention for victims/survivors of gender-based violence as they attend frequently. Interventions that are evidence-based and respond to consensus from victim/survivor voices include universal education, screening in antenatal care, first line supportive care, and referral for advocacy and psychological interventions, including mother-child work. Health care staff require training, protocols, scripts, referral pathways, understanding of cultural safety and antiracist practice in service delivery, and leadership support to undertake this sensitive work, including support, if needed, for their own experiences of gender-based violence. Using a trauma-, violence- and gender-informed approach across health systems, taking into account structural inequities, is…

Continued growth in the number of published clinical studies has necessitated changes to the way evidence-based resources such as clinical guidelines are developed and updated. The Australian and New Zealand Clinical Guidelines for Stroke Management (https://informme.org.au/guidelines/clinical-guidelines-for-stroke-management) are based on continual evidence surveillance and timely updates to recommendations as new research is published. In this article, we outline the main updates to recommendations since the guidelines moved into a living mode in 2018, and discuss key challenges and benefits of living guidelines.

Show me the money: how do we justify spending health care dollars on digital health?Focusing solely on financial measures is unlikely to deliver a comprehensive view of the value of digital health D igital health, which refers to the use of digital technology to provide and support health care services, promises to strengthen health systems worldwide and has been accelerated by the coronavirus disease 2019 (COVID-19) pandemic.1 Amid the rapid digital transformation of health care, 2,3 the value of sizeable digital health investments remains unclear.3,4 The investments required for digital health are often substantial and may come at a cost to existing health care delivery models.Decision makers can be paralysed by a situation where investment in digital health is unavoidable but the conventionally measured short term outcomes often do not provide a convincing fiscal return on investment.2,3 However, health systems are now shifting from perceiving digital health as a cost that needs to be recouped to a quality improvement tool that can positively transform health care.This is because…

Implementation science based health care research is urgently needed for genomic and precision medicine in Australia Precision medicine is a tailored approach to health, incorporating an individual's genetic make-up, environment and lifestyle, and is a new frontier offering much promise for disease prevention and cure.1 Its recent rise has been largely driven by rapid advances in genomic medicine, with sequencing of an individual's genetic code identifying opportunities for precision health care, therapies and diagnostics. Genomics has revolutionised many areas, including public health (eg, population genetic carrier screening and pathogen genomic sequencing during the coronavirus disease 2019 [COVID-19] pandemic), pharmacogenomics (drug metabolism and response genes), cancer management (tumour sequencing for diagnosis and therapy targets), pregnancy management (testing, screening and pre-implantation genetic diagnosis) and rare diseases (Box 1). Medicare item numbers are now approved for genomic diagnostics in cancer, pre-implantation genetic diagnosis, and certain paediatric,…

NCD = non-communicable disease. ◆Framework for building resilience to climate disasters in the health sector

OBJECTIVES: To examine whether pre-hospital emergency medical service care differs for women and men subsequently admitted to hospital with stroke. DESIGN, SETTING, PARTICIPANTS: Population-based cohort study; analysis of linked Admitted Patient Data Collection and NSW Ambulance data for people admitted to New South Wales hospitals with a principal diagnosis of stroke at separation, 1 July 2005 - 31 December 2018. MAIN OUTCOME MEASURES: Emergency medical service assessments, protocols, and management for patients subsequently diagnosed with stroke, by sex. RESULTS: Of 202 231 people hospitalised with stroke (mean age, 73 [SD, 14] years; 98 599 women [51.0%]), 101 357 were conveyed to hospital by ambulance (50.1%). A larger proportion of women than men travelled by ambulance (52.4% v 47.9%; odds ratio [OR], 1.09; 95% CI, 1.07-1.11), but time between the emergency call and emergency department admission was similar for both sexes. The likelihood of being assessed as having a stroke (adjusted OR [aOR], 0.97; 95% CI, 0.93-1.01) or subarachnoid haemorrhage (aOR, 1.22; 95% CI, 0.73-2.03)…

International primary care responses to the coronavirus disease 2019 (COVID-19) pandemic have seen the prioritisation of acute and urgent services for people with COVID-19 as well as seeing many practitioners involved in COVID-19 vaccination counselling and delivery.1, 2 This prioritisation has often resulted in partial or complete disruption to chronic disease management (CDM),1 including care for conditions such as hypertension, diabetes and cancer.2 CDM in Australian primary care has been similarly disrupted, with reports of decreased time spent on CDM activities and preventive care,3 particularly for elements of care that require in-person examination or testing,4 and delays in investigation, diagnosis, referred appointments and elective procedures, resulting in prolonged pain, anxiety and deterioration for patients.5 The introduction of telehealth items under the Medicare Benefits Schedule (MBS) may have both alleviated and contributed to disruption.5-7 Although early data suggested that there was little reduction in the total volume of services provided against the MBS, when…

Chronic traumatic encephalopathy (CTE) is a neurodegenerative tauopathy caused by repetitive head injury.1 Although it has chiefly been studied in contact sport participants, anyone who experiences repetitive head injury is at risk of CTE. It is associated with a range of neuro-psychological problems, ranging from mood and behavioural symptoms to cognitive impairment and dementia.2 Clinical diagnostic criteria have been proposed,3 but, as for many neurodegenerative disorders, a definitive diagnosis requires post mortem brain examination. In 2018, we established the Australian Sports Brain Bank (ASBB; https://www.brainbank.org.au) to support the study of CTE in Australia. The ASBB has since received more than 600 donation pledges from amateur and professional sportspeople. In this article we report preliminary findings based on the first 21 completed donations (to 26 March 2021). The study was approved by the Sydney Local Health District Ethics Review Committee (Royal Prince Alfred Hospital) (reference, X19-0010). All 21 donors had participated in sports with risks of repetitive head…

OBJECTIVES: To assess emergency department (ED) presentation numbers in Queensland during the coronavirus disease 2019 (COVID-19) pandemic to mid-2021, a period of relatively low COVID-19 case numbers. DESIGN: Interrupted time series analysis. SETTING: All 105 Queensland public hospital EDs. MAIN OUTCOME MEASURES: Numbers of ED presentations during the COVID-19 lockdown period (11 March 2020 - 30 June 2020) and the period of easing restrictions (1 July 2020 - 30 June 2021), compared with pre-pandemic period (1 January 2018 - 10 March 2020), overall (daily numbers) and by Australasian Triage Scale (ATS; daily numbers) and selected diagnostic categories (cardiac, respiratory, mental health, injury-related conditions) and conditions (stroke, sepsis) (weekly numbers). RESULTS: During the lockdown period, the mean number of ED presentations was 19.4% lower (95% confidence interval, -20.9% to -17.9%) than during the pre-pandemic period (predicted mean number: 5935; actual number: 4786 presentations). The magnitudes of the decline and the time to return to predicted levels varied by ATS…

OBJECTIVE: To review recent published trials of nutrition and dietary interventions for people with serious mental illness; to assess their effectiveness in improving metabolic syndrome risk factors. STUDY DESIGN: Systematic review and meta-analysis of randomised and non-randomised controlled trials of interventions with a nutrition/diet-related component delivered to people with serious mental illness, published 1 January 2010 - 6 September 2021. Primary outcomes were weight, body mass index (BMI), and waist circumference. Secondary outcomes were total serum cholesterol, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol, triglyceride, and blood glucose levels. DATA SOURCES: MEDLINE, EMBASE, PsycINFO, CINAHL, and CENTRAL databases. In addition, reference lists of relevant publications were examined for further additional studies. DATA SYNTHESIS: Twenty-five studies encompassing 26 intervention arms were included in our analysis. Eight studies were at low or some risk of bias, seventeen were deemed to be at high risk. Eight of seventeen intervention arms…

OBJECTIVE: To assess the short term safety of the COVID-19 vaccines Comirnaty (Pfizer-BioNTech BNT162b2) and Vaxzevria (AstraZeneca ChAdOx1) in Australia. DESIGN: Prospective observational cohort study; online surveys by AusVaxSafety, a national active vaccine safety surveillance system, three and eight days after vaccination. SETTING, PARTICIPANTS: People aged 16 years or more who received COVID-19 vaccines at sentinel vaccination hubs, general practices, or Aboriginal Community Controlled Health Organisation clinics, 22 February - 30 August 2021. MAIN OUTCOME MEASURES: Primary outcome: proportion of respondents who reported any adverse event following immunisation (AEFI) 0-3 days after vaccination. SECONDARY OUTCOMES: proportions of respondents who reported specific adverse events or medical review for AEFI within seven days of vaccination; impact on usual daily activities; recovery. RESULTS: 4 851 480 people received COVID-19 vaccines at participating sentinel sites during the study period (25% of all COVID-19 vaccine doses administered in Australia to 30 August 2021). 3 035 983…

The burden and costs of potentially inappropriate medications (PIMs) and polypharmacy are major public health challenges. Medicines that are ineffective or no longer indicated, discordant with care goals or where harms outweigh benefits should be deprescribed. However, despite the publication of numerous deprescribing studies and guidelines over the past decade, the effectiveness of deprescribing interventions in routine care remains unclear. In this Perspective, we describe the impacts of deprescribing on clinical outcomes, draw insights from recent trials, and discuss opportunities for designing future trials better able to demonstrate the patient-important effects of deprescribing.

OBJECTIVES: To describe the severity and clinical spectrum of coronavirus disease 2019 (COVID-19) in children during the 2021 New South Wales outbreak of the Delta variant of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). DESIGN, SETTING: Prospective cohort study in three metropolitan Sydney local health districts, 1 June - 31 October 2021. PARTICIPANTS: Children under 16 years of age with positive SARS-CoV-2 nucleic acid test results admitted to hospital or managed by the Sydney Children's Hospital Network (SCHN) virtual care team. MAIN OUTCOME MEASURES: Age-specific SARS-CoV-2 infection frequency, overall and separately for SCHN virtual and hospital patients; rates of medical and social reason admissions, intensive care admissions, and paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 per 100 SARS-CoV-2 infections; demographic and clinical factors that influenced likelihood of hospital admission. RESULTS: A total of 17 474 SARS-CoV-2 infections in children under 16 were recorded in NSW, of whom 11 985 (68.6%) received…

A precision medicine approach to asthma places the patient at the centre of their care Asthma is a common inflammatory disease, affecting over 300 million people worldwide,1 including one in nine Australian adults.2 Asthma imposes a major burden on the health care system, on patients, and within society.3 In the late 20th century and the early 2000s, there were major improvements in asthma outcomes, largely because of the introduction of inhaled corticosteroids to treat eosinophilic airway inflammation, and asthma self-management education initiatives.4 These improvements in asthma outcomes are now being lost. Hospitalisations and mortality from asthma have begun to rise as adoption of new assessment techniques and biomarkers into practice stagnates, and we experience sluggish development of new drug discovery in comparison to other diseases.4 Asthma deaths have risen in Australia, the United Kingdom and the United States,4 with at least one person in Australia dying every day from asthma.2 The need to improve outcomes for people with asthma is therefore great. Despite advances in…

Ascites is the pathological accumulation of fluid in the peritoneal cavity.1 Cirrhosis is the commonest cause of ascites in developed countries, followed by malignancy and cardiac failure.1 Ascites is a common presenting sign of hepatic decompensation in cirrhosis, with important prognostic implications.1 Spontaneous bacterial peritonitis is bacterial infection of ascites without any obvious source of infection.1, 2 It occurs in 1–4% of outpatients and 10% of inpatients with ascites secondary to cirrhosis, and can be asymptomatic initially but life-threatening when diagnosis is delayed.1, 3 Ascitic fluid analysis is recommended to evaluate the cause of clinically apparent (grade 2 and 3) ascites (Box 1) at first presentation and to exclude spontaneous bacterial peritonitis in patients with known cirrhosis, clinical deterioration (new neurological, liver or renal dysfunction) or acute gastrointestinal bleeding.1 Paracentesis (from the Greek parakentein, meaning "to pierce at the side") is therefore a useful clinical skill to master. Large volume paracentesis can provide symptomatic…

OBJECTIVE: To evaluate the efficacy and safety of opioids for analgesic therapy for people with osteoarthritis. STUDY DESIGN: Systematic review and meta-analysis of randomised, placebo-controlled trials of opioid therapies for treating the pain of osteoarthritis. The primary outcome was medium term pain relief (six weeks to less than 12 months). Quality of evidence was assessed with GRADE criteria. DATA SOURCES: MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews and Central Register of Controlled Trials, CINAHL, PsycINFO, AMED, and the WHO International Clinical Trials Registry; trials published to 31 October 2020. DATA SYNTHESIS: We extracted pain, disability, health-related quality of life, and adverse events data for 36 eligible trials (overall dose range: 10-210 oral morphine milligram equivalents [MME] per day). Continuous pain and disability outcomes were converted to common 0-100-point scales; changes of less than ten points were deemed to be very small effects. Differences in dichotomous outcomes were expressed as risk ratios. Data were pooled for meta-analysis in…

Australia should develop a sustainable evidence-based pharmacogenomic screening program, with DPYD genotyping at the forefront Pharmacogenomics is the genomic profiling of patients for genetic variants that clinically modify the tolerability and desired effect of specific medications. Patients who carry functional gene variants may have increased or decreased capacity to metabolise medications upon exposure. Some genetic variants, such as those occurring in the cytochrome P450 (CYP) genes, have an impact on multiple medications across different drug classes. Other gene–drug pairs are more specific, such as uridine diphosphate glucuronosyltransferase 1A1 (UGT1A1)–irinotecan or dihydropyrimidine dehydrogenase (DPYD)–fluoropyrimidine chemotherapy.1 Pharmacogenomics represents a multidisciplinary collaborative endeavour, including both clinical pharmacology and clinical pathology disciplines as well as various clinicians, with the shared goal of improving health care delivery for patients through individualisation of prescribing and patient care.2-4 There are many known gene–drug pairs…

Health care in the metaverseTo the Editor: The metaverse is a virtual environment merging physical and digital realities.1 Once the thing of movies, metaverses are tipped to be worth $800 billion by 2024. 2 They have potential to revolutionise digital health care delivery, access, education, and patient outcomes.3 Artificial intelligence (AI)-enabled health care, with metaverse enhancement, could create virtual hospitals, 4 transform clinical workflows and accelerate the diagnosis and treatment of conditions relating to mental health, 5 cardiology, 6,7 ophthalmology, 8 and oral health, 9 for example.

OBJECTIVES: To assess the prevalence and management of anaemia in patients undergoing major abdominal surgery, and the influence of guideline adherence on patient outcomes. DESIGN: Prospective observational cohort study. SETTING: 56 hospitals in Australia and New Zealand. PARTICIPANTS: People aged 18 years or more who underwent major abdominal surgery during two 2-week periods in July 2021. MAIN OUTCOME MEASURES: Proportions of patients managed according to Australian National Blood Authority patient blood management guidelines. SECONDARY OUTCOMES: anaemia prevalence, post-operative complications, length of hospital stay, re-admission within 30 days of discharge. RESULTS: Data were available for 2730 eligible patients (mean age, 56.7 years; SD, 17.3 years), including 1558 women (57.1%). Haemoglobin levels prior to surgery were documented for 2461 of 2727 patients (90.2%), 689 of whom had anaemia (28.0%). Pre-operative anaemia assessment and management were associated with lower likelihood of intra-operative (adjusted odds ratio [aOR], 0.33; 95% CI, 0.19-0.57) and post-operative…

OBJECTIVE: To assess whether ambulance offload time influences the risks of death or ambulance re-attendance within 30 days of initial emergency department (ED) presentations by adults with non-traumatic chest pain. DESIGN, SETTING: Population-based observational cohort study of consecutive presentations by adults with non-traumatic chest pain transported by ambulance to Victorian EDs, 1 January 2015 - 30 June 2019. PARTICIPANTS: Adults (18 years or older) with non-traumatic chest pain, excluding patients with ST elevation myocardial infarction (pre-hospital electrocardiography) and those who were transferred between hospitals or not transported to hospital (eg, cardiac arrest or death prior to transport). MAIN OUTCOME MEASURES: Primary outcome: 30-day all-cause mortality (Victorian Death Index data). SECONDARY OUTCOME: Transport by ambulance with chest pain to ED within 30 days of initial ED presentation. RESULTS: We included 213 544 people with chest pain transported by ambulance to EDs (mean age, 62 [SD, 18] years; 109 027 women [51%]). The median offload time increased from 21…

"The convergence of excessive heat, poor housing, energy insecurity and chronic disease has reached critical levels" Most Australians take safe housing and uninterrupted electricity for granted. Yet in remote Indigenous communities, low quality poorly insulated housing and energy instability are common.1 Most houses require prepaid power cards, resources are meagre, financial literacy is low, and people often have to choose between power and food. New evidence reveals extreme rates of prepaid electricity meters’ disconnection in these communities,2 making people with chronic diseases who depend on cool storage and electrical equipment particularly vulnerable. The convergence of excessive heat, poor housing, energy insecurity and chronic disease has reached critical levels in many parts of northern Australia, and a multisectoral response is needed to avert catastrophe. Medical professionals have a key role to play...

Medically actionable adult-onset genomic conditions 6Hereditary breast and ovarian cancer: high risk for breast, ovarian and prostate cancers due to DNA changes in genes that include BRCA1, BRCA2 and PALB2 3Lynch syndrome: high risk for colorectal, endometrial, ovarian and other cancers due to DNA changes in genes that include MLH, MSH2 and MSH6 4Familial hypercholesterolaemia: increased risk for coronary heart disease due to DNA changes in genes that include LDLR, APOB and PCSK9, causing very high cholesterol levels from an early age 6 13265377, 2022, 6, Downloaded from https://onlinelibrary.wiley.

OBJECTIVE: To identify characteristics associated with the hospitalisation and death of people with COVID-19 living in residential aged care facilities (RACFs). DESIGN: Retrospective cohort study. SETTING, PARTICIPANTS: All confirmed (polymerase chain reaction testing) or probable SARS-CoV-2 infections (rapid antigen tests) in residents of the 86 RACFs in the Metro South Hospital and Health Service area (southeast Queensland), 13 December 2021 - 24 January 2022. MAIN OUTCOME MEASURES: Hospitalisation within 14 days or death within 28 days of COVID-19 diagnosis. RESULTS: Of 1071 RACF residents with COVID-19, 151 were hospitalised within 14 days and 126 died within 28 days of diagnosis. Likelihood of death increased with age (per five years: adjusted odds ratio [aOR], 1.38; 95% confidence interval [CI], 1.21-1.57), but not that of hospitalisation. Men were more likely to be hospitalised (aOR, 1.7; 95% CI, 1.2-2.4) or die (aOR, 2.5; 95% CI, 1.7-3.6) than women. The likelihood of hospitalisation was greater for those with dementia (aOR, 1.9; 95% CI, 1.2-3.0), heart failure (aOR, 1.7;…

OBJECTIVES: To compare the performance of four N95 respirator types with respect to quantitative fit test pass rate and health care worker-rated usability and comfort. DESIGN, SETTING, PARTICIPANTS: Health care workers who participated in the respiratory protection program at the Royal Melbourne Hospital, 1 October 2020 - 31 May 2021. Participants underwent quantitative N95 respirator fit testing (at least three of four types: semi-rigid cup, flat-fold cup, duckbill, and three-panel flat-fold types), and were invited to complete an online usability and comfort assessment for respirators for which their fit test results were passes. MAIN OUTCOME MEASURES: Fit test pass rate, and user-rated overall comfort and assessment ratings (five-point Likert scales), by N95 respirator type. RESULTS: A total of 2161 health care workers underwent quantitative fit testing (women, 1586 [73.4%]; nurses, 1271 [58.8%]). The overall fit test pass rates were 65.0% for the semi-rigid cup respirators (1029/1583 tests), 32.4% for the flat-fold respirator (660/2035 tests), 59.2% for the duckbill respirators…

INTRODUCTION: Type 2 diabetes in young adults (nominally, 18-30 years of age) is a more aggressive condition than that seen in older age, with a greater risk of major morbidity and early mortality. This first Australian consensus statement on the management of type 2 diabetes in young adults considers areas where existing type 2 diabetes guidance, directed mainly towards older adults, may not be appropriate or relevant for the young adult population. Where applicable, recommendations are harmonised with current national guidance for type 2 diabetes in children and adolescents (aged < 18 years). The full statement is available at https://www.diabetessociety.com.au, https://www.adea.com.au and https://www.apeg.org.au. MAIN RECOMMENDATIONS: Advice is provided on important aspects of care including screening, diabetes type, psychological care, lifestyle, glycaemic targets, pharmacological agents, cardiovascular disease risk management, comorbidity assessment, contraception and pregnancy planning, and patient-centred education. Special considerations for Aboriginal and Torres Strait…

•Of the women who gave birth in Australia in 2018, 47% had overweight or obesity, with obesity being associated with both maternal and fetal complications. •Bariatric surgery improves fertility and some pregnancy-related outcomes. •Following bariatric surgery, pregnancy should be delayed by at least 12-18 months due to adverse pregnancy outcomes associated with rapid weight loss. •Contraception should be prescribed after bariatric surgery, although the effectiveness of the oral contraceptive pill may be reduced due to malabsorption and contraceptive devices such as intrauterine devices should be considered as first line therapy. •After bariatric surgery, women should undergo close monitoring for nutritional insufficiencies before, during and after pregnancy. Expert opinion recommends these women undergo dietary assessment and supplementation to prevent micronutrient deficiencies. •Bariatric surgeons, bariatric medical practitioners, bariatric dieticians, the patient's usual general practitioner, obstetricians, and maternity specialists should be involved to assist in the…

Perspective for CONSORT (eg, CONSORT for harms 2 and CONSORT for non-pharmacological studies 24 ) may help researchers to report harms appropriately for all interventions.Such approaches may help reduce the under-or overestimation of the harms of treatments and guide better informed decision making by clinicians, patients and policymakers.

OBJECTIVES: To provide updated estimates of life expectancy at birth for Indigenous and non-Indigenous people in the Northern Territory, 1999-2018; to quantify the contributions of changes in life years lost to disease-specific causes of death to overall changes in life expectancy. DESIGN, SETTING, PARTICIPANTS: Analysis of Australian Coordinating Registry data on underlying and nine multiple causes of death (ICD-10) for deaths in the NT, by age, sex, and Indigenous status, 1 January 1999 - 31 December 2018. MAIN OUTCOME MEASURES: Life expectancy at birth by year and 5-year period, by Indigenous status and sex; change in life expectancy by year and 5-year period, by Indigenous status and sex; contributions in changes in life years lost to leading underlying causes of death, by 5-year period, Indigenous status and sex. RESULTS: Life expectancy for Indigenous men increased from 56.6 years in 1999 to 65.6 years in 2018 (change, 9.0 years; 95% CI, 7.9-10.0 years) and from 64.8 to 69.7 years for Indigenous women (4.9 years; 95% CI, 3.2-6.7 years); for non-Indigenous men, it increased…

Long COVID: sustained and multiplied disadvantage

OBJECTIVE: To examine associations between area-level socio-economic factors and the incidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in Victoria during 2020. DESIGN, SETTING: Population-level ecological study of the incidence of SARS-CoV-2 infections in Victoria, by postcode, 1 March - 13 August 2020. MAIN OUTCOME MEASURES: Relationships between the incidence of SARS-CoV-2 infections by postcode (Department of Health and Human Services data published on The Age website), and demographic, education level, ethnic background, economic and employment-related factors, housing-related factors, and social disadvantage (Australian Bureau of Statistics data for 2014-19), expressed as incidence rate ratios (IRRs). RESULTS: During the study period, 15 482 SARS-CoV-2 infections with associated postcodes were recorded in Victoria. Incidence was higher for metropolitan than regional postcodes (418.3 v 62 infections per 100 000 population; IRR, 6.2; 95% CI, 4.6-8.2). In regional postcodes, incidence rose with mean household size (per person: IRR, 7.30; 95% CI,…

OBJECTIVE: To determine the distribution of ABO RhD blood groups in Australia in 2019. DESIGN: Retrospective analysis of blood group data for blood donors (Australian Red Cross Lifeblood National Blood Management System) and for people whose blood type was determined in samples submitted for analysis by hospital-based or private pathology agencies. SETTING: All Australian states and territories, 1 January - 31 December 2019. MAIN OUTCOME MEASURES: Proportions of donors and patients, by ABO blood group and RhD status. These proportions were compared with published data for 1993-94 first-time blood donors. RESULTS: A total of 1 318 751 valid ABO RhD blood group results were provided by 28 of 41 invited pathology agencies (including 245 of 324 approved health providers, 76%). Valid ABO RhD data were available for 490 491 blood donors, including 103 798 first-time donors (21.2%). Blood group prevalence based on samples typed by pathology services was O RhD+, 38.4%; O RhD-, 6.5%; A RhD+, 32.0%; A RhD-, 5.6%; B RhD+, 11.8%; B RhD-, 1.5%; AB RhD+, 3.7%; and AB RhD-, 0.5% (totals: RhD+,…

OBJECTIVES: To assess the use of NHMRC Indigenous research guidelines by Australian researchers and the degree of Aboriginal and Torres Strait Islander governance and participation in Indigenous health research. DESIGN, SETTING, PARTICIPANTS: Cross-sectional survey of people engaged in Indigenous health research in Australia, comprising respondents to an open invitation (social media posts in general and Indigenous health research networks) and authors of primary Indigenous health research publications (2015-2019) directly invited by email. MAIN OUTCOME MEASURES: Reported use of NHMRC guidelines for Indigenous research; reported Indigenous governance and participation in Indigenous health research. RESULTS: Of 329 people who commenced the survey, 247 people (75%) provided responses to all questions, including 61 Indigenous researchers (25%) and 195 women (79%). The NHMRC guidelines were used "all the time" by 206 respondents (83%). Most respondents (205 of 247, 83%) reported that their research teams included Indigenous people, 139 reported dedicated Indigenous advisory boards…

Abstract Purpose Within the context of a review of a Doctor of Medicine graduate curriculum, medical students partnered with faculty staff to co-develop a novel curriculum resource exemplifying the integration of planetary determinants of health into existing medical curricula. Method We undertook qualitative methodologies involving a planetary health literature review and curriculum mapping exercise in three parts between April 2018 - May 2021. In part one, a student focus group sought students’ perceptions on opportunities for climate-change related teaching. Part two involved two 5-hour workshops that mapped planetary health principles to classical organ systems-based teaching areas. Part three consisted of curriculum mapping expert review. Results Participatory workshops involved 26 students and positioned students as leaders and partners in curriculum development alongside academics and clinicians. Final synthesis produced a comprehensive infographic rich document covering seven organ systems plus healthcare’s ecological footprint, the role of medical students and opportunities…

Obtaining high quality evidence relating to adoption of robotic surgery presents challenges Surgery performed using a robotic platform has led to a step change in how some procedures, largely urological, are delivered. Robotic systems are perceived to be advantageous over laparoscopic and open surgery by providing stereoscopic 3D vision with magnification of the surgical field and precise controlled instrument movement to allow dissection in confined spaces and complex manoeuvres such as suturing. That said, the global adoption of robotic surgery in other specialities has not been at pace, despite what seem to be clear benefits for patients undergoing some complex pelvic and abdominal procedures. Approximately 1.2 million robotic procedures had been performed worldwide as of December 2020, most of which were robotic-assisted radical prostatectomies (RARPs).1 By contrast, many colorectal and gynaecological procedures remain within the remit of laparoscopic or traditional open surgery. In this article, we discuss the evidence and controversy relating to adoption of robotic surgery,…