Showing papers in "The Medical Journal of Australia in 2018"

Clinical Oncology Society of Australia position statement on exercise in cancer care

Abstract: Introduction: Clinical research has established exercise as a safe and effective intervention to counteract the adverse physical and psychological effects of cancer and its treatment. This article summarises the position of the Clinical Oncology Society of Australia (COSA) on the role of exercise in cancer care, taking into account the strengths and limitations of the evidence base. It provides guidance for all health professionals involved in the care of people with cancer about integrating exercise into routine cancer care. Main recommendations: COSA calls for: • exercise to be embedded as part of standard practice in cancer care and to be viewed as an adjunct therapy that helps counteract the adverse effects of cancer and its treatment; • all members of the multidisciplinary cancer team to promote physical activity and recommend that people with cancer adhere to exercise guidelines; and • best practice cancer care to include referral to an accredited exercise physiologist or physiotherapist with experience in cancer care. Changes in management as a result of the guideline: COSA encourages all health professionals involved in the care of people with cancer to: • discuss the role of exercise in cancer recovery; • recommend their patients adhere to exercise guidelines (avoid inactivity and progress towards at least 150 minutes of moderate intensity aerobic exercise and two to three moderate intensity resistance exercise sessions each week); and • refer their patients to a health professional who specialises in the prescription and delivery of exercise (ie, accredited exercise physiologist or physiotherapist with experience in cancer care).

Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000-2015.

Abstract: Objectives To investigate the incidence and demographic features of anterior cruciate ligament (ACL) reconstructions in Australia by age and sex, and to determine whether the incidence has changed during the past 15 years. Design and setting Descriptive epidemiological analysis of longitudinal data on ACL reconstructions (July 2000 - June 2015) in the National Hospital Morbidity Database. Main outcome measures Population ACL reconstruction rates, by age group and sex. Results 197 557 primary ACL reconstructions were performed during the study period; the annual incidence increased by 43% (from 54.0 to 77.4 per 100 000 population), and by 74% among those under 25 years of age (from 52.6 to 91.4 per 100 000 population). In males, the peak incidence in 2014-15 was for 20-24-year-olds (283 per 100 000 population); for females, it was for 15-19-year-olds (164 per 100 000 population). Annual growth in incidence was greatest in the 5-14-year-old age group (boys, 7.7%; girls, 8.8%). Direct hospital costs of ACL reconstruction surgery in 2014-15 were estimated to be $142 million. The annual incidence of revision ACL reconstructions increased from 2.49 (2000-01) to 5.65 per 100 000 population (2014-15), or by 5.6% per year; revisions as a proportion of all ACL reconstruction increased from 4.4% to 6.8%. Conclusions The increasing incidence of ACL reconstructions in young Australians over 15 years is worrying. The individuals at greatest risk are men aged 20-24 years and women aged 15-19 years; the rate of reconstruction is increasing most rapidly among those aged 5-14 years. Revision rates are increasing more rapidly than those of primary reconstructions.

National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the diagnosis and management of atrial fibrillation 2018

Abstract: INTRODUCTION Atrial fibrillation (AF) is increasing in prevalence and is associated with significant morbidity and mortality. The optimal diagnostic and treatment strategies for AF are continually evolving and care for patients requires confidence in integrating these new developments into practice. These clinical practice guidelines will assist Australian practitioners in the diagnosis and management of adult patients with AF. Main recommendations: These guidelines provide advice on the standardised assessment and management of patients with atrial fibrillation regarding: screening, prevention and diagnostic work-up; acute and chronic arrhythmia management with antiarrhythmic therapy and percutaneous and surgical ablative therapies; stroke prevention and optimal use of anticoagulants; and integrated multidisciplinary care. Changes in management as a result of the guideline: Opportunistic screening in the clinic or community is recommended for patients over 65 years of age. The importance of deciding between a rate and rhythm control strategy at the time of diagnosis and periodically thereafter is highlighted. β-Blockers or non-dihydropyridine calcium channel antagonists remain the first line choice for acute and chronic rate control. Cardioversion remains first line choice for acute rhythm control when clinically indicated. Flecainide is preferable to amiodarone for acute and chronic rhythm control. Failure of rate or rhythm control should prompt consideration of percutaneous or surgical ablation. The sexless CHA2DS2-VA score is recommended to assess stroke risk, which standardises thresholds across men and women; anticoagulation is not recommended for a score of 0, and is recommended for a score of ≥ 2. If anticoagulation is indicated, non-vitamin K oral anticoagulants are recommended in preference to warfarin. An integrated care approach should be adopted, delivered by multidisciplinary teams, including patient education and the use of eHealth tools and resources where available. Regular monitoring and feedback of risk factor control, treatment adherence and persistence should occur.

Differences in management and outcomes for men and women with ST-elevation myocardial infarction.

Abstract: Objective: To examine whether there are sex differences in the characteristics, management, and clinical outcomes of patients with an ST-elevation myocardial infarction (STEMI).Design, setting: Cohort study; analysis of data collected prospectively by the CONCORDANCE acute coronary syndrome registry from 41 Australian hospitals between February 2009 and May 2016.Participants: 2898 patients (2183 men, 715 women) with STEMI.Main outcome measures: Rates of revascularisation (percutaneous coronary intervention [PCI], thrombolysis, coronary artery bypass grafting [CABG]), adjusted for GRACE risk score quartile. Secondary outcomes: timely vascularisation rates; major adverse cardiac event rates; clinical outcomes and preventive treatments at discharge.Results: The mean age of women with STEMI at presentation was 66.6 years (SD, 14.5 years), of men, 60.5 years (SD, 12.5 years). The proportions of women with hypertension, diabetes, prior stroke, chronic kidney disease, chronic heart failure, or dementia were Larger than those of men; fewer women had histories of previous coronary artery disease or myocardial infarction, or of prior PCI or CABG. Women were Less likely to have undergone coronary angiography (odds ratio, adjusted for GRACE score quartile [aOR], 0.53; 95% CI, 0.41-0.69) or revascularisation (aOR, 0.42; 95% CI, 0.34-0.52); they were Less likely to have received timely revascularisation (aOR, 0.72; 95% CI, 0.63-0.83) or primary PCI (aOR, 0.76; 95% CI, 0.61-0.95). Six months after admission, the rates of major adverse cardiovascular events (aOR, 2.68; 95% CI, 1.76-4.09) and mortality (aOR, 2.17; 95% CI, 1.24-3.80) were higher for women. At discharge, significantly fewer women than men received beta-blockers, statins, and referrals to cardiac rehabilitation.Conclusion: Women with STEMI are Less likely to receive invasive management, revascularisation, or preventive medication at discharge. The reasons for these persistent differences in care require investigation.

The management of epilepsy in children and adults

Abstract: The International League Against Epilepsy has recently published a new classification of epileptic seizures and epilepsies to reflect the major scientific advances in our understanding of the epilepsies since the last formal classification 28 years ago. The classification emphasises the importance of aetiology, which allows the optimisation of management. Antiepileptic drugs (AEDs) are the main approach to epilepsy treatment and achieve seizure freedom in about two-thirds of patients. More than 15 second generation AEDs have been introduced since the 1990s, expanding opportunities to tailor treatment for each patient. However, they have not substantially altered the overall seizure-free outcomes. Epilepsy surgery is the most effective treatment for drug-resistant focal epilepsy and should be considered as soon as appropriate trials of two AEDs have failed. The success of epilepsy surgery is influenced by different factors, including epilepsy syndrome, presence and type of epileptogenic lesion, and duration of post-operative follow-up. For patients who are not eligible for epilepsy surgery or for whom surgery has failed, trials of alternative AEDs or other non-pharmacological therapies, such as the ketogenic diet and neurostimulation, may improve seizure control. Ongoing research into novel antiepileptic agents, improved techniques to optimise epilepsy surgery, and other non-pharmacological therapies fuel hope to reduce the proportion of individuals with uncontrolled seizures. With the plethora of gene discoveries in the epilepsies, "precision therapies" specifically targeting the molecular underpinnings are beginning to emerge and hold great promise for future therapeutic approaches.

Primary care management of non-specific low back pain: key messages from recent clinical guidelines.

Abstract: Introduction: Research in the past decade supports some major changes to the primary care management of non‐specific low back pain (LBP). The present article summarises recommendations from recently published United Kingdom, Danish, Belgian and United States guidelines to alert readers to the important changes in recommendations for management, and the recommendations from previous guidelines that remain unchanged.

Chronic idiopathic constipation in adults: epidemiology, pathophysiology, diagnosis and clinical management.

Abstract: Chronic idiopathic constipation (CIC) is one of the most common gastrointestinal disorders, with a global prevalence of 14%. It is commoner in women and its prevalence increases with age. There are three subtypes of CIC: dyssynergic defaecation, slow transit constipation and normal transit constipation, which is the most common subtype. Clinical assessment of the patient with constipation requires careful history taking, in order to identify any red flag symptoms that would necessitate further investigation with colonoscopy to exclude colorectal malignancy. Screening for hypercalcaemia, hypothyroidism and coeliac disease with appropriate blood tests should be considered. A digital rectal examination should be performed to assess for evidence of dyssynergic defaecation. If this is suspected, further investigation with high resolution anorectal manometry should be undertaken. Anorectal biofeedback can be offered to patients with dyssynergic defaecation as a means of correcting the associated impairment of pelvic floor, abdominal wall and rectal functioning. Lifestyle modifications, such as increasing dietary fibre, are the first step in managing other causes of CIC. If patients do not respond to these simple changes, then treatment with osmotic and stimulant laxatives should be trialled. Patients not responding to traditional laxatives should be offered treatment with prosecretory agents such as lubiprostone, linaclotide and plecanatide, or the 5-HT4 receptor agonist prucalopride, where available. If there is no response to pharmacological treatment, surgical intervention can be considered, but it is only suitable for a carefully selected subset of patients with proven slow transit constipation.

Presentations to NSW emergency departments with self-harm, suicidal ideation, or intentional poisoning, 2010-2014.

Abstract: Objective To evaluate population trends in presentations for mental health problems presenting to emergency departments (EDs) in New South Wales during 2010-2014, particularly patients presenting with suicidal ideation, self-harm, or intentional poisoning. Design, setting and participants This was a retrospective, descriptive analysis of linked Emergency Department Data Collection registry data for presentations to NSW public hospital EDs over five calendar years, 2010-2014. Patients were included if they had presented to an ED and a mental health-related diagnosis was recorded as the principal diagnosis. Main outcome measures Rates of mental health-related presentations to EDs by age group and calendar year, both overall and for the subgroups of self-harm, suicidal ideation and behaviour, and intentional poisoning presentations. Results 331 493 mental health-related presentations to 115 NSW EDs during 2010-2014 were analysed. The presentation rate was highest for 15-19-year-old patients (2014: 2167 per 100 000 population), but had grown most rapidly for 10-14-year-old children (13.8% per year). The combined number of presentations for suicidal ideation, self-harm, or intentional poisoning increased in all age groups, other than those aged 0-9 years; the greatest increase was for the 10-19-year-old age group (27% per year). Conclusions The rate of mental health presentations to EDs increased significantly in NSW between 2010 and 2014, particularly presentations by adolescents. Urgent action is needed to provide better access to adolescent mental health services in the community and to enhance ED models of mental health care. The underlying drivers of this trend should be investigated to improve mental health care.

Thyroid nodules: diagnosis and management

Abstract: Thyroid nodules are common. Their importance lies in the need to assess thyroid function, degree of and future risk of mass effect, and exclude thyroid cancer, which occurs in 7-15% of thyroid nodules. There are four key components to thyroid nodule assessment: clinical history and examination, serum thyroid stimulating hormone (TSH) measurement, ultrasound and, if indicated, fine-needle aspiration (FNA). If the serum TSH is suppressed, a thyroid scan with 99Tc can distinguish between a solitary hot nodule, a toxic multinodular goitre or, less commonly, thyroiditis or Graves' disease within a coexisting nodular thyroid. Scintigraphically cold nodules are evaluated in the same way as in the setting of normal or elevated serum TSH levels. Thyroid ultrasonography should be performed only for palpable goitre and thyroid nodules and by specialists with expertise in thyroid sonography. Routine thyroid cancer screening is not recommended, except in high risk individuals, as the detection of early thyroid cancer has not been shown to improve survival. FNA may be performed for nodules ≥ 1.0 cm depending on clinical and sonographic risk factors for thyroid cancer. FNA specimens should be read by an experienced cytopathologist and be reported according to the Bethesda Classification System. Molecular analysis of indeterminate FNA samples has potential to better discriminate benign from malignant nodules and thus guide management. Surgery is indicated for FNA findings of malignancy or indeterminate cytology when there is a high risk clinical context. Surgery may also be indicated for suspicion of malignancy; larger nodules, especially with symptoms of mass effect; and in some patients with thyrotoxicosis.

Homeless health care: meeting the challenges of providing primary care.

Abstract: People experiencing homelessness have multiple complex health conditions yet are typically disengaged from primary health care services and place a significant burden on the acute health system. Barriers preventing people who are homeless from accessing primary care can be both personal and practical and include competing needs and priorities, illness and poor health, physical access to health services, difficulty in contacting services, medication security, and the affordability of health care. Differences in social status and perceptions of being judged can lead to relationship barriers to accessing primary care. Key solutions include prioritising access to stable housing, continuity of health care, specialised homeless general practice, hospital inreach, discharge planning and coordinated care, general practice outreach, and medical recovery centres.

Australian standards of care and treatment guidelines for transgender and gender diverse children and adolescents.

Abstract: INTRODUCTION The Australian standards of care and treatment guidelines aim to maximise quality care provision to transgender and gender diverse (TGD) children and adolescents across Australia, while recognising the unique circumstances of providing such care to this population. Recommendations are made based on available empirical evidence and clinician consensus, and have been developed in consultation with Australian professionals from multiple disciplines working with the TGD population, TGD support organisations, as well as TGD children and adolescents and their families. Main recommendations: Recommendations include general principles for supporting TGD children and adolescents using an affirmative approach, separate guidelines for the care of pre-pubertal children and TGD adolescents, as well as discipline-based recommendations for mental health care, medical and surgical interventions, fertility preservation, and speech therapy. Changes in management as a result of this statement: Although published international treatment guidelines currently exist, challenges in accessing and providing TGD health care specific to Australia have not been addressed to date. In response to this, these are the first guidelines to be developed for TGD children and adolescents in Australia. These guidelines also move away from treatment recommendations based on chronological age, with recommended timing of medical transition and surgical interventions dependent on the adolescent's capacity and competence to make informed decisions, duration of time on puberty suppression, coexisting mental health and medical issues, and existing family support.

RedUSe: reducing antipsychotic and benzodiazepine prescribing in residential aged care facilities.

Abstract: OBJECTIVE To assess the impact of a multi-strategic, interdisciplinary intervention on antipsychotic and benzodiazepine prescribing in residential aged care facilities (RACFs). Design, setting: Prospective, longitudinal intervention in Australian RACFs, April 2014 - March 2016. PARTICIPANTS 150 RACFs (with 12 157 residents) comprised the main participant group; two further groups were consultant pharmacists (staff education) and community pharmacies (prescribing data). Data for all RACF residents, excluding residents receiving respite or end-stage palliative care, were included. INTERVENTION A multi-strategic program comprising psychotropic medication audit and feedback, staff education, and interdisciplinary case review at baseline and 3 months; final audit at 6 months. MAIN OUTCOME MEASURE Mean prevalence of regular antipsychotic and benzodiazepine prescribing at baseline, and at 3 and 6 months. Secondary measures: chlorpromazine and diazepam equivalent doses/day/resident; proportions of residents for whom drug was ceased or the dose reduced; prevalence of antidepressant and prn (as required) psychotropic prescribing (to detect any substitution practice). RESULTS During the 6-month intervention, the proportion of residents prescribed antipsychotics declined by 13% (from 21.6% [95% CI, 20.4-22.9%] to 18.9% [95% CI, 17.7-20.1%]), and that of residents regularly prescribed benzodiazepines by 21% (from 22.2% [95% CI, 21.0-23.5%] to 17.6% [95% CI, 16.5-18.7]; each, P < 0.001). Mean chlorpromazine equivalent dose declined from 22.9 mg/resident/day (95% CI, 19.8-26.0) to 20.2 mg/resident/day (95% CI, 17.5-22.9; P < 0.001); mean diazepam equivalent dose declined from 1.4 mg/resident/day (95% CI, 1.3-1.5) to 1.1 mg/resident/day (95% CI, 0.9-1.2; P < 0.001). For 39% of residents prescribed antipsychotics and benzodiazepines at baseline, these agents had been ceased or their doses reduced by 6 months. There was no substitution by sedating antidepressants or prn prescribing of other psychotropic agents. CONCLUSIONS The RedUSe program achieved significant reductions in the proportions of RACF residents prescribed antipsychotics and benzodiazepines. TRIAL REGISTRATION Australian New Zealand Clinical Trials, ACTRN12617001257358.

Translation and implementation of the Australian-led PCOS guideline: clinical summary and translation resources from the International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome

Abstract: __Introduction:__ We have developed the first international evidence-based guideline for the diagnosis and management of polycystic ovary syndrome (PCOS), with an integrated translation program incorporating resources for health professionals and consumers. The development process involved an extensive Australian-led international and multidisciplinary collaboration of health professionals and consumers over 2 years. The guideline is approved by the National Health and Medical Research Council and aims to support both health professionals and women with PCOS in improving care, health outcomes and quality of life. A robust evaluation process will enable practice benchmarking and feedback to further inform evidence-based practice. We propose that this methodology could be used in developing and implementing guidelines for other women's health conditions and beyond. __Main recommendations:__ The recommendations cover the following broad areas: diagnosis, screening and risk assessment depending on life stage; emotional wellbeing; healthy lifestyle; pharmacological treatment for non-fertility indications; and assessment and treatment of infertility. __Changes in management as a result of this guideline:__ •Diagnosis: 1) when the combination of hyperandrogenism and ovulatory dysfunction is present, ultrasound examination of the ovaries is not necessary for diagnosis of PCOS in adult women; 2) requires the combination of hyperandrogenism and ovulatory dysfunction in young women within 8 years of menarche, with ultrasound examination of the ovaries not recommended, owing to the overlap with normal ovarian physiology; and 3) adolescents with some clinical features of PCOS, but without a clear diagnosis, should be regarded as "at risk" and receive follow-up assessment. •Screening for metabolic complications has been refined and incorporates both PCOS status and additional metabolic risk factors. •Treatment of infertility: letrozole is now first line treatment for infertility as it improves live birth rates while reducing multiple pregnancies compared with clomiphene citrate.

Paediatric mental and physical health presentations to emergency departments, Victoria, 2008–15

Abstract: Objectives To identify trends in presentations to Victorian emergency departments (EDs) by children and adolescents for mental and physical health problems; to determine patient characteristics associated with these presentations; to assess the relative clinical burdens of mental and physical health presentations. Design Secondary analysis of Victorian Emergency Minimum Dataset (VEMD) data. Participants, setting: Children and young people, 0-19 years, who presented to public EDs in Victoria, 2008-09 to 2014-15. Main outcome measures Absolute numbers and proportions of mental and physical health presentations; types of mental health diagnoses; patient and clinical characteristics associated with mental and physical health presentations. Results Between 2008-09 and 2014-15, the number of mental health presentations increased by 6.5% per year, that of physical health presentations by 2.1% per year; the proportion of mental health presentations rose from 1.7% to 2.2%. Self-harm accounted for 22.5% of mental health presentations (11 770 presentations) and psychoactive substance use for 22.3% (11 694 presentations); stress-related, mood, and behavioural and emotional disorders together accounted for 40.3% (21 127 presentations). The rates of presentations for self-harm, stress-related, mood, and behavioural and emotional disorders each increased markedly over the study period. Patients presenting with mental health problems were more likely than those with physical health problems to be triaged as urgent (2014-15: 66% v 40%), present outside business hours (36% v 20%), stay longer in the ED (65% v 82% met the National Emergency Access Target), and be admitted to hospital (24% v 18%). Conclusions The number of children who presented to Victorian public hospital EDs for mental health problems increased during 2008-2015, particularly for self-harm, depression, and behavioural disorders.

Health-related quality of life burden in severe asthma.

Abstract: It is largely unrecognised that the impacts of asthma are different in patients with severe disease compared with patients with mild to moderate disease. Severe asthma is associated with a significant health-related quality of life (HRQoL) burden due to excessive symptoms, frequent and life-threatening attacks, increased comorbidity burden, and high pharmacological treatment requirements. Interventions aimed at improving HRQoL need to be specifically tested in populations with severe asthma, including multicomponent interventions targeting the many clinical characteristics associated with the disease. It is necessary to have patient-reported outcome measures developed specifically for severe asthma. Public health messages recognising the significant burden of severe asthma on quality of life are needed.

Psychological distress in remote mining and construction workers in Australia.

Abstract: OBJECTIVES To assess the prevalence and correlates of psychological distress in a sample of remote mining and construction workers in Australia. Design, setting: A cross-sectional, anonymous Wellbeing and Lifestyle Survey at ten mining sites in South Australia and Western Australia, administered at meetings held during 2013-2015. PARTICIPANTS 1124 employees at remote construction, and open cut and underground mining sites completed the survey. MAIN OUTCOME MEASURES General psychological distress (Kessler Psychological Distress Scale, K10) and self-reported overall mental health status; work, lifestyle and family factors correlated with level of psychological distress. RESULTS The final sample comprised 1124 workers; 93.5% were men, 63% were aged 25-44 years. 311 respondents (28%) had K10 scores indicating high/very high psychological distress, compared with 10.8% for Australia overall. The most frequently reported stressors were missing special events (86%), relationship problems with partners (68%), financial stress (62%), shift rosters (62%), and social isolation (60%). High psychological distress was significantly more likely in workers aged 25-34 years (v ≥ 55 years: odds ratio [OR], 3.2; P = 0.001) and workers on a 2 weeks on/1 week off roster (v 4 weeks on/1 week off: OR, 2.4; P < 0.001). Workers who were very or extremely stressed by their assigned tasks or job (OR, 6.2; P = 0.004), their current relationship (OR, 8.2; P < 0.001), or their financial situation (OR, 6.0; P < 0.001) were significantly more likely to have high/very high K10 scores than those not stressed by these factors. Workers who reported stress related to stigmatisation of mental health problems were at the greatest risk of high/very high psychological distress (v not stressed: OR, 23.5; P < 0.001). CONCLUSIONS Psychological distress is significantly more prevalent in the remote mining and construction workforce than in the overall Australian population. The factors that contribute to mental ill health in these workers need to be addressed, and the stigma associated with mental health problems reduced.

Drought-related stress among farmers: findings from the Australian Rural Mental Health Study

Abstract: Objectives To investigate general and drought-related stress experienced by farmers at both the personal and community levels, and whether socio-demographic and community factors influence this stress. Design Multivariate analysis of data from the Australian Rural Mental Health Study (ARMHS), a longitudinal cohort study (2007-2013). Setting Non-metropolitan New South Wales. Participants Subset of 664 ARMHS participants (at baseline) who identified as living or working on a farm. Main outcome measures Personal drought-related stress (PDS), community drought-related stress (CDS), and general psychological distress (K10 score). Results Farmers who were under 35, both lived and worked on a farm, experienced greater financial hardship, and were in outer regional, remote or very remote NSW reported PDS particularly frequently. Of these factors, only being under 35 and increased remoteness were associated with higher incidence of CDS. Mild wet weather during the prior 12 months reduced PDS and CDS but increased general distress. Moderate or extreme wet weather did not affect PDS or general distress, but moderate wet weather was associated with increased CDS. Drought-related stress and general psychological distress were influenced by different socio-demographic and community factors. Conclusions Farmers in NSW experience significant stress about the effects of drought on themselves, their families, and their communities. Farmers who are younger, live and work on a farm, experience financial hardship, or are isolated are at particular risk of drought-related stress. Medical practitioners who provide assistance to farmers and farming communities can contribute to initiatives that relieve stress about drought.

Cognitive impairment during pregnancy: a meta-analysis

Abstract: Objectives Many women report declines in cognitive function during pregnancy, but attempts to empirically evaluate such changes have yielded inconsistent results. We aimed to determine whether pregnancy is associated with objective declines in cognitive functioning, and to assess the progression of any declines during pregnancy. Study design We undertook a meta-analysis, applying a random effects model, of 20 studies that have reported quantitative relationships between pregnancy and changes in cognition. Data sources Full text articles indexed by Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete, MEDLINE Complete, and PsychINFO. Data synthesis The 20 studies assessed included 709 pregnant women and 521 non-pregnant women. Overall cognitive functioning was poorer in pregnant women than in non-pregnant women (standardised mean difference [SMD], 0.52 [95% CI, 0.07-0.97]; P = 0.025). Analysis of cross-sectional studies found that general cognitive functioning (SMD, 1.28 [95% CI 0.26-2.30]; P = 0.014), memory (SMD, 1.47 [95% CI, 0.27-2.68]; P = 0.017), and executive functioning (SMD, 0.46 [95% CI, 0.03-0.89]; P = 0.036) were significantly reduced during the third trimester of pregnancy (compared with control women), but not during the first two trimesters. Longitudinal studies found declines between the first and second trimesters in general cognitive functioning (SMD, 0.29 [95% CI, 0.08-0.50]; P = 0.006) and memory (SMD, 0.33 [95% CI, 0.12-0.54]; P = 0.002), but not between the second and third trimesters. Conclusions General cognitive functioning, memory, and executive functioning were significantly poorer in pregnant than in control women, particularly during the third trimester. The differences primarily develop during the first trimester, and are consistent with recent findings of long term reductions in brain grey matter volume during pregnancy. The impact of these effects on the quality of life and everyday functioning of pregnant women requires further investigation.

Non-motor Parkinson disease: new concepts and personalised management

Abstract: Most patients with Parkinson disease (PD) have non-motor symptoms (NMS), and on average these can range from four to 19 different symptoms. NMS dominate the prodromal phase of PD and some may serve as clinical biomarkers of PD. NMS can be dopaminergic, non-dopaminergic, of genetic origin or drug induced. Clinical assessment of NMS should include the NMS Questionnaire (completed by patients) for screening, as recommended by the International Parkinson and Movement Disorders Society and other international societies. The total number of NMS in a patient with PD constitutes the NMS burden, which can be graded using validated cut-off scores on the NMS Questionnaire and Scale and can be used as an outcome measure in clinical trials. Despite NMS burden having a major effect on the quality of life of patients and carers, a large European study showed that NMS are often ignored in the clinic. The syndromic nature of PD is underpinned by non-motor subtypes which are likely to be related to specific dysfunction of cholinergic, noradrenergic, serotonergic pathways in the brain, not just the dopaminergic pathways. NMS can be treated by dopaminergic and non-dopaminergic strategies, but further robust studies supported by evidence from animal models are required. The future of modern treatment of PD needs to be supported by the delivery of personalised medicine.

Medicinal cannabis in Australia, 2016: the Cannabis as Medicine Survey (CAMS-16)

Abstract: Objective To explore patterns of cannabis use for medical purposes in Australia immediately prior to the 2016 legislation for frameworks for medical cannabis use. Design, setting: Anonymous online survey with convenience sample, April-October 2016. Participants were recruited through online media and at professional and consumer forums. Participants Adults (at least 18 years of age) who reported using a cannabis product for self-identified medical or therapeutic reasons during the preceding 12 months. Main outcome measures Consumer characteristics; indications and patterns of medical cannabis use; perceived benefits and harms; views on appropriate availability of medical cannabis. Results Most of the 1748 participants were men (68.1%) and employed (56.6%), with a mean age of 37.9 years (SD, 13.4 years) and mean reported period of medical cannabis use of 9.8 years (SD, 12.5 years). The most frequent reasons for medical cannabis use were anxiety (50.7%), back pain (50.0%), depression (49.3%), and sleep problems (43.5%). Respondents had used medical cannabis on a mean of 19.9 of the previous 28 days (SD, 10.0 days), spending a mean $68.60 (SD, $85.00) per week, and 83.4% had inhaled the substance. Participants reported high levels of clinical effectiveness and frequent side effects, including drowsiness, ocular irritation, lethargy and memory impairment; 17% met DSM-5 criteria for moderate or severe cannabis use disorder. Many reported harms or concerns related to the illicit status of cannabis. Participants believed that medical cannabis should be integrated into mainstream health care, and that products should be required to meet consistency and safety standards. Conclusion Illicitly sourced cannabis is used to treat a broad range of medical conditions in Australia. Future models of prescribed medical cannabis take consumer patterns of use and demand into consideration.

Dr Google in the ED: searching for online health information by adult emergency department patients.

Abstract: Objective To determine the prevalence, predictors, and characteristics of health-related internet searches by adult emergency department (ED) patients; to examine the effect of searching on the doctor-patient relationship and treatment compliance. Design A multi-centre, observational, cross-sectional study; a purpose-designed 51-item survey, including tools for assessing e-health literacy (eHEALS) and the effects of internet searching on the doctor-patient relationship (ISMII). Setting, participants: 400 adult patients presenting to two large tertiary referral centre emergency departments in Melbourne, February-May 2017. Outcome measures Descriptive statistics for searching prevalence and characteristics, doctor-patient interaction, and treatment compliance; predictors of searching; effect of searching on doctor-patient interaction. Results 400 of 1056 patients screened for eligibility were enrolled; their mean age was 47.1 years (SD, 21.1 years); 51.8% were men. 196 (49.0%) regularly searched the internet for health information; 139 (34.8%) had searched regarding their current problem before presenting to the ED. The mean ISMII score was 30.3 (95% CI, 29.6-31.0); searching improved the doctor-patient interaction for 150 respondents (77.3%). Younger age (per 10-year higher age band: odds ratio [OR], 0.74; 95% CI, 0.61-0.91) and greater e-health literacy (per one-point eHEALS increase: OR, 1.11; 95% CI, 1.06-1.17) predicted searching the current problem prior to presentation; e-health literacy predicted ISMII score (estimate, 0.39; 95% CI, 0.20-0.39). Most patients would never or rarely doubt their diagnosis (79%) or change their treatment plan (91%) because of conflicting online information. Conclusion Online health care information was frequently sought before presenting to an ED, especially by younger and e-health literate patients. Searching had a positive impact on the doctor-patient interaction and was unlikely to reduce adherence to treatment.

The MJA-Lancet Countdown on health and climate change: Australian policy inaction threatens lives

Abstract: Climate plays an important role in human health and it is well established that climate change can have very significant impacts in this regard. In partnership with The Lancet and the MJA, we present the inaugural Australian Countdown assessment of progress on climate change and health. This comprehensive assessment examines 41 indicators across five broad sections: 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. These indicators and the methods used for each are largely consistent with those of the Lancet Countdown global assessment published in October 2017, but with an Australian focus. Significant developments include the addition of a new indicator on mental health. Overall, we find that Australia is vulnerable to the impacts of climate change on health, and that policy inaction in this regard threatens Australian lives. In a number of respects, Australia has gone backwards and now lags behind other high income countries such as Germany and the United Kingdom. Examples include the persistence of a very high carbon-intensive energy system in Australia, and its slow transition to renewables and low carbon electricity generation. However, we also find some examples of good progress, such as heatwave response planning. Given the overall poor state of progress on climate change and health in Australia, this country now has an enormous opportunity to take action and protect human health and lives. Australia has the technical knowhow and intellect to do this, and our annual updates of this assessment will track Australia’s engagement with and progress on this vitally important issue.

Salt consumption by Australian adults: a systematic review and meta-analysis.

Abstract: Objective Salt reduction is a public health priority because it is a leading contributor to the global burden of disease. As in Australia there is uncertainty about the current level of salt intake, we sought to estimate current levels. Study design Random effects meta-analysis of data from 31 published studies and one unpublished dataset that reported salt or sodium consumption by Australian adults on the basis of 24-hour urine collections or dietary questionnaires. Data sources MEDLINE (via Ovid) and EMBASE (to August 2016). Data synthesis Thirty-one published studies and one unpublished dataset (1989-2015; 16 836 individuals) were identified. The mean weighted salt consumption estimated from 24-hour urine collections was 8.70 g/day (95% CI, 8.39-9.02 g/day); after adjusting for non-urinary salt excretion, the best estimate of salt intake in Australia is 9.6 g/day. The mean weighted intake was 10.1 g/day (95% CI, 9.68-10.5 g/day) for men and 7.34 g/day (95% CI, 6.98-7.70 g/day) for women. Mean weighted consumption was 6.49 g/day (95% CI, 5.94-7.03 g/day) when measured with diet diaries, 6.76 g/day (95% CI, 5.48-8.05 g/day) when assessed with food frequency questionnaires, and 6.73 g/day (95% CI, 6.34-7.11) when assessed by dietary recall. Salt intake had not decreased between 1989 and 2015 (R2 = -0.02; P = 0.36). Conclusion Salt intake in Australian adults exceeds the WHO-recommended maximum of 5 g/day and does not appear to be declining. Measuring salt intake with methods based on self-reporting can substantially underestimate consumption. The data highlight the need for ongoing action to reduce salt consumption in Australia and robust monitoring of population salt intake.

Identifying and treating codeine dependence: a systematic review.

Abstract: Objectives Codeine dependence is a significant public health problem, motivating the recent rescheduling of codeine in Australia (1 February 2018) To provide information for informing clinical responses, we undertook a systematic review of what is known about identifying and treating codeine dependence Study design Articles published in English that described people who were codeine-dependent or a clinical approach to treating people who were codeine-dependent, without restriction on year of publication, were reviewed Articles not including empirical data were excluded One researcher screened each abstract; two researchers independently reviewed full text articles Study quality was assessed, and data were extracted with standardised tools Data sources MEDLINE and EMBASE were searched for relevant publications on 22 November 2016 The reference lists of eligible studies were searched to identify further relevant publications 2150 articles were initially identified, of which 41 were eligible for inclusion in our analysis Data synthesis Studies consistently reported specific characteristics associated with codeine dependence, including mental health comorbidity and escalation of codeine use attributed to psychiatric problems Case reports and series described codeine dependence masked by complications associated with overusing simple analgesics and delayed detection Ten studies described the treatment of codeine dependence Three reports identified a role for behavioural therapy; the efficacy of CYP inhibitors in a small open label trial was not confirmed in a randomised controlled trial; four case series/chart reviews described opioid agonist therapy and medicated inpatient withdrawal; two qualitative studies identified barriers related to perceptions of codeine-dependent people and treatment providers, and confirmed positive perceptions and treatment outcomes achieved with opioid agonist treatments Conclusion Strategies for identifying problematic codeine use are needed Identifying codeine dependence in clinical settings is often delayed, contributing to serious morbidity Commonly described approaches for managing codeine dependence include opioid taper, opioid agonist treatment, and psychological therapies These approaches are consistent with published evidence for pharmaceutical opioid dependence treatment and with broader frameworks for treating opioid dependence PROSPERO registration: CRD42016052129

Nicotine replacement therapy for smoking cessation during pregnancy.

Abstract: Nicotine replacement therapy (NRT) is recommended in current Australian clinical guidelines for pregnant women who are unable to quit smoking unassisted. Clinicians report low levels of prescribing NRT during pregnancy, due to safety concerns and low levels of confidence in their ability to prescribe NRT. Animal models show that nicotine is harmful to the fetus, especially for brain and lung development, but human studies have not found any harmful effects on fetal and pregnancy outcomes. Studies of efficacy and effectiveness in the real world suggest that NRT use during pregnancy increases smoking cessation rates. These rates may be hampered by the fact that studies so far have used an NRT dose that does not adequately account for the higher nicotine metabolism during pregnancy and, therefore, does not adequately treat withdrawal symptoms. Further research is needed to assess the safety and efficacy of higher dosages of NRT in pregnancy, specifically of combination treatment using dual forms of NRT. As NRT is safer than smoking, clinicians need to offer this option to all pregnant women who smoke. A practical guide for initiating and tailoring the dose of NRT in pregnancy is suggested.

Appropriate use of oral corticosteroids for severe asthma

Abstract: Severe asthma represents a significant burden of disease, particularly in high income nations; oral corticosteroids (OCS) remain an important part of the management toolkit for these patients. Corticosteroids are effective at targeting numerous elements of the type 2/eosinophilic inflammatory pathway and lead to both rapid reduction in eosinophilic inflammation and longer term reduction in airway hyper-responsiveness. Resistance or insensitivity to corticosteroids is a feature of severe asthma, with persistent type 2 inflammation often occurring despite regular use of OCS. OCS remain the only accepted, effective treatment for acute asthma, and also continue to play an important role in the long term management of severe asthma, in spite of their significant side effect profile. Even with the availability of the new biological therapies against IgE and interleukin-5, it is likely that a large proportion of patients will continue to require OCS to control their asthma. Future work should focus on optimising the balance between OCS efficacy and safety, and continued development of agents that allow reduction, or ideally discontinuation of their use, is needed.

Tick-induced allergies: mammalian meat allergy and tick anaphylaxis.

Abstract: Mammalian meat allergy after tick bites and tick anaphylaxis are the most serious tick-induced allergies. They are often severe, should be largely avoidable and offer fascinating insights into the development and prevention of allergies. Australian clinicians reported the first cases of tick anaphylaxis and discovered the association between tick bites and the development of mammalian meat allergy. The subsequent finding of the allergen epitope within the meat responsible for the allergic reaction, α-gal (galactose-α-1,3-galactose), stimulated further interest in this emergent allergy. Reports of mammalian meat allergy associated with bites from several tick species have now come from every continent where humans are bitten by ticks. The number of diagnosed patients has continued to rise. Clinically, mammalian meat allergy and tick anaphylaxis present quite differently. The prominent role of cofactors in triggering episodes of mammalian meat allergy can make its diagnosis difficult. Management of mammalian meat allergy is complicated by the manifold potential therapeutic implications due to the widespread distribution of the mammalian meat allergen, α-gal. Exposures to α-gal-containing medications have proved lethal in a minority of people, and fatal tick anaphylaxis has been reported in Australia. Prevention of tick bites is prudent and practicable; killing the tick in situ is crucial to both primary and secondary prevention of allergic reactions. Mechanisms in the development of mammalian meat allergy constitute a paradigm for how allergies might arise.

Multimorbidity among Aboriginal people in New South Wales contributes significantly to their higher mortality.

Abstract: Objectives To compare the prevalence of multimorbidity and its impact on mortality among Aboriginal and non-Aboriginal Australians who had been hospitalised in New South Wales in the previous 10 years. Design, setting and participants Cohort study analysis of linked NSW hospital (Admitted Patient Data Collection) and mortality data for 5 437 018 New South Wales residents with an admission to a NSW hospital between 1 March 2003 and 1 March 2013, and alive at 1 March 2013. Main outcome measures Admissions for 30 morbidities during the 10-year study period were identified. The primary outcome was the presence or absence of multimorbidity during the 10-year lookback period; the secondary outcome was mortality in the 12 months from 1 March 2013 to 1 March 2014. Results 31.5% of Aboriginal patients had at least one morbidity and 16.1% had two or more, compared with 25.0% and 12.1% of non-Aboriginal patients. After adjusting for age, sex, and socio-economic status, the prevalence of multimorbidity among Aboriginal people was 2.59 times that for non-Aboriginal people (95% CI, 2.55-2.62). The prevalence of multimorbidity was higher among Aboriginal people in all age groups, in younger age groups because of the higher prevalence of mental morbidities, and from age 60 because of physical morbidities. The age-, sex- and socio-economic status-adjusted hazard of one-year mortality (Aboriginal v non-Aboriginal Australians) was 2.43 (95% CI, 2.24-2.62), and 1.51 (95% CI, 1.39-1.63) after also adjusting for morbidity count. Conclusions The prevalence of multimorbidity was higher among Aboriginal than non-Aboriginal patients, and this difference accounted for much of the difference in mortality between the two groups. Evidence-based interventions for reducing multimorbidity among Aboriginal and Torres Strait Islander Australians must be a priority.

Unintended and unwanted pregnancy in Australia: a cross-sectional, national random telephone survey of prevalence and outcomes.

Abstract: lannedparenthoodhas important benefits formaternal and infant health. Monitoring and preventing unintended P pregnancy is therefore an important public health goal. In the only Australian national household survey about mistimed or unintended pregnancy (undertaken 2005), 18% of women of reproductive age (18e44 years) reported that their most recent pregnancy was mistimed, and a further 17% reported that the pregnancy was unwanted.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders: major depression summary.

Abstract: INTRODUCTION In December 2015, the Royal Australian and New Zealand College of Psychiatrists published a comprehensive set of mood disorder clinical practice guidelines for psychiatrists, psychologists and mental health professionals This guideline summary, directed broadly at primary care physicians, is an abridged version that focuses on major depression It emphasises the importance of shared decision making, tailoring personalised care to the individual, and delivering care in the context of a therapeutic relationship In practice, the management of depression is determined by a multitude of factors, including illness severity and putative aetiology, with the principal objectives of regaining premorbid functioning and improving resilience against recurrence of future episodes Main recommendations: The guidelines emphasise a biopsychosocial lifestyle approach and provide the following specific clinical recommendations: Alongside or before prescribing any form of treatment, consideration should be given to the implementation of strategies to manage stress, ensure appropriate sleep hygiene and enable uptake of healthy lifestyle changes For mild to moderate depression, psychological management alone is an appropriate first line treatment, especially early in the course of illness For moderate to severe depression, pharmacological management is usually necessary and is recommended first line, ideally in conjunction with psychosocial interventions Changes in management as a result of the guidelines: The management of depression is anchored within a therapeutic relationship that attends to biopsychosocial lifestyle aspects and psychiatric diagnosis The guidelines promote a broader approach to the formulation and management of depression, with treatments tailored to depressive subtypes and administered with clear steps in mind Lifestyle and psychological therapies are favoured for less severe presentations, and concurrent antidepressant prescription is reserved for more severe and otherwise treatment-refractory cases