Medical Journal of Australia最新文献

{"title":"Mental health training for physicians supervising resident physicians: a cluster randomised controlled trial","authors":"Aimée Gayed, Jessica Strudwick, Nathasha Kugenthiran, Anthony D LaMontagne, Andrew Mackinnon, Helen Christensen, Nicholas Glozier, Samuel Harvey","doi":"10.5694/mja2.52407","DOIUrl":"10.5694/mja2.52407","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To evaluate an online training program for physician supervisors with the aim of promoting a mentally healthy workplace by improving their use of both responsive and preventive mental health support strategies.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study design</h3>\u0000 \u0000 <p>Cluster randomised, waitlist-controlled trial.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Setting, participants</h3>\u0000 \u0000 <p>Royal Australasian College of Physicians fellows who were supervising at least one resident physician in any of the 31 primary health networks in Australia and 20 district health boards in New Zealand (health network clusters).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Intervention</h3>\u0000 \u0000 <p>A brief online skills-based mental health training program, comprising twelve modules grouped into three topics: common mental illnesses; helping trainees you are concerned about (responsive strategies); and minimising mental health risks at work (preventive strategies).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Main outcome measures</h3>\u0000 \u0000 <p>Change between baseline and the 3-month assessment in self-reported recommended supervisor behaviours; differences between intervention and control groups in recommended behaviour scores three weeks, three months, and six months after the program.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Ninety physicians from 20 health network clusters were allocated to the intervention group, 88 physicians from 22 clusters to the control group. Intervention group participants reported greater positive change in behaviour across the study period than those in the control group (mixed model repeated measures analysis, group × time interaction: <i>P</i> < 0.001). The mean change in self-reported supervisory behaviour score was higher for the intervention than the control group at the 3-week (mean difference in score, 1.6; 95% confidence interval [CI], 0.8–2.4), 3-month (0.9; 95% CI, 0.2–1.6), and 6-month assessments (1.9; 95% CI, 1.1–2.7). The mean change in self-reported responsive behaviour score was also greater for the intervention group at the 3-week (mean difference, 2.3; 95% CI, 1.5–3.1), 3-month (1.0; 95% CI, 0.2–1.9), and 6-month assessments (2.0; 95% CI, 1.1–2.9); differences in the mean change in preventive behaviour scores were statistically significant at the 3-week (mean difference, 1.1; 95% CI, 0.1–2.2) and 6-month assessments (1.8; 95% CI, 0.8","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":null,"pages":null},"PeriodicalIF":6.7,"publicationDate":"2024-08-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52407","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141988284","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Gender affirmation testosterone therapy, Australia, 2021–22: a review of PBS dispensing data","authors":"Brendan J Nolan, Sav Zwickl, Jeffrey D Zajac, Ada S Cheung","doi":"10.5694/mja2.52415","DOIUrl":"10.5694/mja2.52415","url":null,"abstract":"<p>In Australia, as overseas, the number of transgender and gender-diverse (trans) people seeking hormone therapy for gender affirmation is increasing.<span><sup>1</sup></span> By aligning a person's physical characteristics with their gender identity, such therapy improves psychological wellbeing, reducing gender dysphoria and depression and improving quality of life.<span><sup>2, 3</sup></span> It is unknown how many trans people use testosterone therapy for gender affirmation in Australia.</p><p>The costs of medications for most medical conditions are subsidised for Australians by the federal government Pharmaceutical Benefits Scheme (PBS). Some medications, including testosterone, require PBS Authorities approval (“authority prescription”). As the PBS does not list gender affirmation as an indication for prescribing testosterone, clinicians use the authority indication “androgen deficiency due to an established pituitary or testicular disorder”, regardless of gender identity markers, in accordance with national guidelines.<span><sup>4</sup></span></p><p>Our aim was to estimate the number of trans people who received PBS-subsidised testosterone for gender affirmation in Australia during 1 July 2021 – 30 June 2022. Our request for PBS dispensing data was approved by the Services Australia External Request Evaluation Committee (RMS2527). The number of people supplied testosterone (item codes 10378F, 08830R, 08619P, 11740X, 10380H, 02115H, 10205D) by age group at 30 June 2022 was provided in aggregate, deidentified form. The testosterone formulations prescribed for trans people to increase testosterone concentrations to the male reference range (10–30 nmol/L) are the same as those used to treat men with hypogonadism.<span><sup>4</sup></span> The proportion of people to whom testosterone was dispensed for whom a current or past female gender marker was recorded was determined by Services Australia; we interpreted a current or past female gender marker as a surrogate marker for a trans man.</p><p>Of the 38 633 people dispensed PBS-subsidised testosterone during 1 July 2021 – 30 June 2022, current or past female gender markers were recorded for 6998 (18%). The proportion differed markedly by age group: 6394 of 10 805 people aged 40 years or younger had current or past female gender markers (59%), including 3795 of 4726 people aged 16–25 years (80%), but only 33 of 12 114 people over 65 years of age (0.3%) (Box).</p><p>We suspect that trans people probably comprised a substantial proportion of the Australians dispensed PBS-subsidised testosterone during 2021–22, particularly among those under 40 years of age. As there are no specific PBS items for gender affirmation treatment, people seeking medical gender affirmation may remain untreated or pay for it themselves, potentially limiting access. A specific PBS authority indication for “gender affirmation” is needed, ideally without requiring consultation with a specialist, to monitor prescribing activit","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":null,"pages":null},"PeriodicalIF":6.7,"publicationDate":"2024-08-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52415","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141988283","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Calling time on the use of modified-release opioids for acute pain","authors":"Pamela E Macintyre, Melissa A Jamcotchian, Jennifer A Stevens","doi":"10.5694/mja2.52417","DOIUrl":"10.5694/mja2.52417","url":null,"abstract":"<p>The first modified-release (MR) formulation of oxycodone was approved for the management of pain in 1995 and aggressively marketed (with false claims of a low addiction risk) primarily for the management of chronic non-cancer pain.<span><sup>1</sup></span> In many high income countries, including Australia,<span><sup>2</sup></span> prescription of MR oxycodone for the management of acute pain, especially post-operative pain, then became commonplace.<span><sup>1</sup></span> This occurred despite no evidence at the time showing that MR oxycodone was better — in terms of analgesia and/or adverse effects — than immediate-release (IR) oxycodone alone (as explained below).<span><sup>1, 3, 4</sup></span> A survey of Australian public and private hospital pharmacists showed that MR opioids were commonly prescribed to opioid-naïve patients with acute pain in more than 70% of hospitals — both as an inpatient and at discharge.<span><sup>2</sup></span></p><p>Guidelines reflecting the current evidence base and aiming to improve the safety of opioid use for acute pain management in Australia have recently been introduced.<span><sup>5, 6</sup></span> These strongly recommend against the initiation of MR opioids for acute pain in opioid-naïve patients. Opioids remain an important part of multimodal acute pain analgesic regimens, with guidelines indicating how to use IR opioids more safely and effectively, while not limiting appropriate access and dosing for patients who require them.</p><p>Calling time on initiating MR opioids for acute pain is a key recommendation of these guidelines and aims to reduce opioid risk in two key areas: in-hospital morbidity and mortality, and inadvertent persistent post-discharge opioid use (PPOU), which comes with its own list of potential adverse effects.<span><sup>7</sup></span></p><p>In 2000, regulatory changes made by the Australian Therapeutics Goods Administration were designed to decrease the risk of harm from prescription opioids.<span><sup>8</sup></span> Included in the changes were that MR opioids should not be used for the management of severe pain unless the pain is opioid-responsive and “requires daily, continuous, long term treatment” (thus excluding acute pain).<span><sup>8</sup></span> In 2022, the Australian Commission on Safety and Quality in Health Care published their Opioid Analgesic Stewardship in Acute Pain Clinical Care Standards, which advised that MR opioid use for the management of acute pain “should be exceptional and not routine”.<span><sup>5</sup></span> In the same year, a new Choosing Wisely Australia statement said “Avoid routine prescription of slow-release (SR) opioids in the management of acute pain, in hospital and community settings, unless there is a demonstrated need, close monitoring is available, and a cessation plan is in place”.<span><sup>9</sup></span> A 2023 publication from the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine contains similar recomm","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":null,"pages":null},"PeriodicalIF":6.7,"publicationDate":"2024-08-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52417","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141988282","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The loneliness epidemic: a holistic view of its health and economic implications in older age","authors":"Lidia Engel, Cathrine Mihalopoulos","doi":"10.5694/mja2.52414","DOIUrl":"10.5694/mja2.52414","url":null,"abstract":"<p>Loneliness has been described as an epidemic and is one of the most pressing public health concerns in Australia and internationally.<span><sup>1, 2</sup></span> In contrast to social isolation, which is an objective measure of social interactions and relationships, loneliness is defined as a subjective experience where one perceives a discrepancy between desired and actual social relationships in terms of quality or quantity.<span><sup>3</sup></span> Although it is common and natural to feel lonely at times, prolonged and intense periods of loneliness have been linked to adverse health outcomes.<span><sup>4</sup></span> Older adults are more prone to loneliness and social isolation compared with other age groups.<span><sup>5</sup></span> Reasons for this include significant life transitions and events, such as retiring from work, increased financial difficulties, loss of friends and widowhood, changes in living arrangements (eg, transitioning to residential aged care), increase in solitary living, and a decline in both health and independence.<span><sup>5, 6</sup></span> Older people at particular risk of loneliness include those living on low incomes, living with a disability, living in rural areas or with housing stress, who are single, childless or living alone, who are vulnerable or at risk of elder abuse, and those with low levels of literacy or communication technology skills (Box).<span><sup>7</sup></span> A growing body of evidence has highlighted the significant health burden associated with loneliness, with more recent studies also suggesting that loneliness has become an economic problem due to an increase in service use and demand for institutional care. This development requires both effective and cost-effective strategies to tackle loneliness.<span><sup>11, 12</sup></span></p><p>A recent meta-analysis found that 28.5% of older people aged 60 years and above experience some degree of loneliness.<span><sup>13</sup></span> Although the study did not observe that loneliness is more common in people aged over 75 years than in those aged 65–75 years, other studies have found that the old (75–84 years) and oldest old (≥ 85 years) are more affected by loneliness than the youngest old (65–74 years).<span><sup>1, 14</sup></span> The prevalence of loneliness among institutionalised older adults is less well documented but a recent meta-analysis estimated the mean prevalence of moderate and severe loneliness in older people living in care homes at 61% and 35% respectively.<span><sup>15</sup></span> Determining the prevalence of loneliness remains a challenge due to its subjective nature, the stigma attached to it, and measurement problems. The use of a direct, single-question measure of loneliness appears to be commonly applied in national surveys and research studies because it is simple and generates fewer missing values. On the flip side, such measures are prone to ambiguous interpretation of the term loneliness and under-reporting due t","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":null,"pages":null},"PeriodicalIF":6.7,"publicationDate":"2024-08-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52414","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141982749","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"“Social prescribing” another stolen Indigenous concept?","authors":"Uday N Yadav,&nbsp;Rosemary Wyber,&nbsp;Fiona Cornforth (Wuthathi/Maluilgal),&nbsp;Raymond W Lovett (Wongaibon/Ngiyampaa)","doi":"10.5694/mja2.52413","DOIUrl":"10.5694/mja2.52413","url":null,"abstract":"<p><span>To the Editor:</span> Holistic comprehensive care is <i>the</i> core of community-controlled primary care services for Aboriginal and Torres Strait Islander peoples. To achieve this, Aboriginal and Torres Strait Islander community-controlled health organisations (ACCHOs) have routinely delivered or connected people using these services since 1971 to address the myriad of socio-economic and cultural determinants through a caring approach rooted in Indigenous knowledge and practices.<span>¹</span> In addition to biomedical and allied health referrals, ACCHOs broker and provide a suite of social and cultural connections with housing, education and legal aid services.<span>²</span> This connected, comprehensive model of care is the core business of ACCHOs, and it does not have a special name.</p><p>Internationally, and in Australia, there is a growing focus on social prescribing programs. Social prescribing has been described as “pioneered” in the United Kingdom during the 1980s–1990s and provides a formal process for primary health care workers to connect patients to a wide range of non-clinical services and supports tailored to their needs.<span>³</span> These encompass healthy lifestyle support services, financial assistance, housing and community gardening, ultimately enhancing health and wellbeing.<span>⁴</span> There has been a surge in social prescribing research and policy interest globally. However, the ACCHO model has been delivering holistic care for patients and the community with a more sustainable workforce model that needs to be recognised, celebrated, replicated and shared nationally and globally.</p><p>A common feature of settler colonialism is the appropriation of lands, knowledge and concepts in the name of discovery.<span>⁵</span> This supplanting of holistic care with social prescribing is another demonstration of the continuing settler colonial approach, where the Aboriginal and Torres Strait Islander holistic model has been erased and reframed as social prescribing. There has been scant acknowledgement that social prescribing has been happening in ACCHOs across Australia for decades. A national funding model must be developed to adequately support the ACCHO sector, provide flexible, holistic care models, and expertly guide how the concept is adopted by primary care. While doing so, it is crucial to have a directory of culturally safe and responsive services, need assessment tools, and linking data on referrals and services to people to measure outcomes. Importantly, Australian academics, policy makers and the primary care sector should acknowledge this long history and learn from it by looking to Indigenous models of “social prescribing” that address the holistic needs of people to guide the implementation of social prescribing programs in Australia.</p><p>No relevant disclosures.</p>","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":null,"pages":null},"PeriodicalIF":6.7,"publicationDate":"2024-08-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52413","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141982748","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Sensitivity and specificity of Aboriginal-developed items to supplement the adapted PHQ-9 screening measure for depression: results from the Getting it Right study","authors":"Timothy Skinner,&nbsp;Alex Brown,&nbsp;Armando Teixeira-Pinto,&nbsp;Sara F Farnbach,&nbsp;Nicholas Glozier,&nbsp;Deborah A Askew,&nbsp;Graham Gee,&nbsp;Alan Cass,&nbsp;Maree L Hackett","doi":"10.5694/mja2.52406","DOIUrl":"10.5694/mja2.52406","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To determine the psychometric properties of an Aboriginal and Torres Strait Islander-developed depressive symptom screening scale.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Design</h3>\u0000 \u0000 <p>Prospective diagnostic accuracy study.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Setting</h3>\u0000 \u0000 <p>Ten primary health care services or residential alcohol and other drug rehabilitation services in Australia that predominantly serve Aboriginal and Torres Strait Islander peoples.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Participants</h3>\u0000 \u0000 <p>500 adults (18 years or older) who identified as Aboriginal and/or Torres Strait Islander and were able to communicate sufficiently to respond to questionnaire and interview questions. Recruitment occurred between 25 March 2015 and 2 November 2016.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Main outcome measure</h3>\u0000 \u0000 <p>Criterion validity of seven Aboriginal and Torres Strait Islander-developed items, using the adapted Patient Health Questionnaire 9 (aPHQ-9) and depression module of the Mini International Neuropsychiatric Interview (MINI) 6.0.0 as the criterion standards.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>The seven-item scale had good internal consistency (α = 0.83) and correlated highly with the aPHQ-9 (ρ = 0.76). All items were significantly associated with diagnosis of a current major depressive episode. Discriminant function and decision tree analysis identified three items forming a summed scale that classified 85% of participants correctly. These three items showed equivalent sensitivity and specificity to the aPHQ-9 when compared with the MINI-identified diagnosis of a current major depressive episode.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>Three items developed by and for Aboriginal and Torres Strait Islander people may provide effective, efficient and culturally appropriate screening for depression in Aboriginal and Torres Strait Islander health care contexts.</p>\u0000 </section>\u0000 </div>","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":null,"pages":null},"PeriodicalIF":6.7,"publicationDate":"2024-08-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52406","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141976100","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Should medical eponyms continue to be used in everyday practice?","authors":"Leya Nedumannil,&nbsp;Diana Lewis","doi":"10.5694/mja2.52416","DOIUrl":"10.5694/mja2.52416","url":null,"abstract":"&lt;p&gt;An eponymous term is an entity named after the person who first described, produced or performed it. In the medical world, eponyms have traditionally been a means of commemorating an individual's contribution towards their field of practice. Several arguments which support the preservation of eponyms exist, including that exceptional people deserve to have their achievements acknowledged, that these terms are well recognised in the medical community, and that eponyms possess educational value as a memory device for the learning and retention of complex medical concepts. For many, changing medical eponymous terms could represent an enormous feat potentially met with unwarranted confusion and, possibly, even indignance among traditionalists.&lt;/p&gt;&lt;p&gt;One key issue encompassing medical eponyms is their potential to falsely promote medical discoveries as the product of a single individual's efforts while neglecting the broader team that contributed. An example is Crohn disease, first described in an article that was actually co-authored by two additional medical practitioners, Oppenheimer and Ginzburg.&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt; Medical progress is seldom a solo feat, and the use of eponyms may threaten important values of collaboration and collegiality in this realm.&lt;/p&gt;&lt;p&gt;Further, eponyms may reinforce the enduring issue of representation of women in medicine, or lack thereof. Numerous women have historically had their scientific achievements forgotten or inaccurately credited to men, a notion of systemic bias so widespread that it has ironically acquired an evocative eponymous title itself, named after suffragist Matilda Gage.&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; Indeed, women account for less than 4% of identified medical eponyms,&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt; of which several are compound names shared with men, a stark reminder of the historical lack of opportunity there was for women to carve their name in the medical sphere. This is of particular relevance to current society with the recent striking release on the significant gender pay gap in Australia, including in medicine.&lt;span&gt;&lt;sup&gt;4&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;The unrestrained use of medical eponyms has also progressively come under scrutiny due to potentially glorifying the memory of individuals complicit in unethical methods of research historically veiled under the guise of scientific progress. Several articles quote the medical misconducts of the Nazi era as a reason to advocate for the removal of eponyms that honour physicians involved in crimes against humanity.&lt;span&gt;&lt;sup&gt;5&lt;/sup&gt;&lt;/span&gt; There has been a resultant change witnessed in the use of eponymous terms enshrouded by their dark past. An example is the replacement of Wegener granulomatosis with granulomatosis with polyangiitis, due to Friedrich Wegener's associations with the Nazi Party.&lt;span&gt;&lt;sup&gt;6&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;The liberal use of medical eponymous terms also places users at risk of inadvertently contributing to the persistence of colonialism and i","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":null,"pages":null},"PeriodicalIF":6.7,"publicationDate":"2024-08-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52416","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141976101","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A case of visceral leishmaniasis masquerading as autoimmune hepatitis","authors":"Vinny Ea,&nbsp;Brigitte Papa,&nbsp;Rimma Goldberg","doi":"10.5694/mja2.52412","DOIUrl":"10.5694/mja2.52412","url":null,"abstract":"&lt;p&gt;A 72-year-old man with a history of well controlled type 2 diabetes was admitted to a tertiary metropolitan hospital for investigation of fevers, night sweats and unintentional weight loss of 18 kg over six months. He had pancytopenia with no symptoms or signs to suggest a focal infection, malignancy or rheumatological disease. Prior outpatient investigation findings revealed mild splenomegaly, with a normal bone marrow aspirate and positron emission tomography scan. At its nadir, the haemoglobin level was 106 g/L (reference interval [RI], 125–175 g/L), white cell count 1.9 × 10&lt;sup&gt;9&lt;/sup&gt;/L (RI, 4.0–11.0 × 10&lt;sup&gt;9&lt;/sup&gt;/L), neutrophil count 1.2 × 10&lt;sup&gt;9&lt;/sup&gt;/L (RI, 2.00–8.00 × 10&lt;sup&gt;9&lt;/sup&gt;/L) and platelets 120 × 10&lt;sup&gt;9&lt;/sup&gt;/L (RI, 150–450 × 10&lt;sup&gt;9&lt;/sup&gt;/L). Notably, liver function test results were mildly elevated in a mixed pattern with alkaline phosphatase 138 U/L (RI, 30–110 U/L), γ-glutamyl transferase 605 U/L (RI, 5–50 U/L) and alanine aminotransferase 78 U/L (RI, 5–40 U/L), with associated antinuclear antibody titre of more than 1280 (RI, &lt; 160), and an elevated immunoglobulin G level of 38.6 g/L (RI, 7.5–15.6 g/L). Pertinent negative results included negative human immunodeficiency virus (HIV) and viral hepatitis serology, and negative anti-smooth muscle and anti-liver–kidney microsomal antibodies. Given these findings and the ongoing diagnostic dilemma, a liver biopsy was performed, showing mild interface hepatitis and lymphoplasmacytic infiltrate in the portal tracts (Box 1), and leading to a probable diagnosis of autoimmune hepatitis. Administration of azathioprine 25 mg and prednisolone 40 mg daily was initiated and the patient was discharged following improvement of his liver function test results.&lt;/p&gt;&lt;p&gt;The patient re-presented two weeks later due to worsening night sweats with no new localising symptoms and was found to have febrile neutropenia (neutrophil count, 0.4 × 10&lt;sup&gt;9&lt;/sup&gt;/L). Administration of empiric antibiotics was started, and azathioprine was stopped due to possible contribution to worsening myelosuppression. As the patient was born in coastal Greece and had travelled there two years prior, leishmaniasis was raised as a differential diagnosis. A repeat bone marrow aspirate revealed &lt;i&gt;Leishmania&lt;/i&gt; amastigotes under microscopy (Box 2) and polymerase chain reaction (PCR) testing was positive for &lt;i&gt;Leishmania donovani&lt;/i&gt; complex. The patient was treated with intravenous liposomal amphotericin 3 mg/kg/dose on Days 1–5, Day 14 and Day 21, which led to resolution of symptoms and pancytopenia six weeks after treatment.&lt;/p&gt;&lt;p&gt;Visceral leishmaniasis is a vector-borne zoonotic disease primarily caused by parasites of the &lt;i&gt;L. donovani&lt;/i&gt; complex (includes &lt;i&gt;L. donovani&lt;/i&gt; and &lt;i&gt;Leishmania infantum&lt;/i&gt;) and is transmitted via infected sandflies.&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt; Globally, visceral leishmaniasis features on the World Health Organization list of neglected tropical diseases, with a significant b","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":null,"pages":null},"PeriodicalIF":6.7,"publicationDate":"2024-08-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52412","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141917035","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Understanding modelled economic evaluations: a reader's guide for clinicians","authors":"Winnie Chen,&nbsp;Martin Howell,&nbsp;Alan Cass,&nbsp;Gillian Gorham,&nbsp;Kirsten Howard","doi":"10.5694/mja2.52409","DOIUrl":"10.5694/mja2.52409","url":null,"abstract":"&lt;p&gt;Economic evaluations have a long history in health care.&lt;span&gt;&lt;sup&gt;1, 2&lt;/sup&gt;&lt;/span&gt; Full economic evaluations aim to inform decision making through comparing the costs and outcomes of two or more interventions, strategies, programs or policies, to estimate their efficiency via an incremental cost-effectiveness ratio. The premise for conducting economic evaluations is that health care resources are finite, and there is an opportunity cost when resources are allocated to one health care intervention over another.&lt;span&gt;&lt;sup&gt;3, 4&lt;/sup&gt;&lt;/span&gt; In Australia, economic evaluations are important considerations in policy decisions on what should be publicly funded under the Pharmaceutical Benefits Scheme (PBS)&lt;span&gt;&lt;sup&gt;5&lt;/sup&gt;&lt;/span&gt; and Medicare Benefits Schedule (MBS).&lt;span&gt;&lt;sup&gt;6&lt;/sup&gt;&lt;/span&gt; Furthermore, clinician–researchers are increasingly considering both clinical effectiveness and cost-effectiveness in evaluation studies and funding applications.&lt;/p&gt;&lt;p&gt;Full economic evaluations are classified by the type of evaluation, with the most common types being cost-effectiveness analysis (CEA), cost–utility analysis (CUA) and cost–benefit analysis (CBA).&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt; The method for conducting these economic evaluations can be study-based or decision–analytic model-based, or both.&lt;span&gt;&lt;sup&gt;7&lt;/sup&gt;&lt;/span&gt; Modelled economic evaluations can overcome some of the limitations associated with study-based economic evaluations.&lt;span&gt;&lt;sup&gt;7, 8&lt;/sup&gt;&lt;/span&gt; The complexity and use of modelled evaluations has increased with improved computing power and data availability. Several published articles offer clinicians an introduction to economic evaluations,&lt;span&gt;&lt;sup&gt;1, 9, 10&lt;/sup&gt;&lt;/span&gt; but few to date have focused on modelled evaluations.&lt;span&gt;&lt;sup&gt;11, 12&lt;/sup&gt;&lt;/span&gt; In this key research skills article, we aim to improve clinician understanding of modelled evaluations. In the Supporting Information, we illustrate key modelling concepts using two recently published models in the &lt;i&gt;Medical Journal of Australia&lt;/i&gt;.&lt;/p&gt;&lt;p&gt;Why are model-based evaluations done? Modelled evaluations can be performed alongside empiric studies or as standalone studies. Modelled evaluations do not replace study-based evaluations — rather, they enable evidence synthesis across multiple studies into relevant decision-making contexts, extrapolation of trial-based results beyond the time horizon, and hypothesis generation where data are unavailable.&lt;span&gt;&lt;sup&gt;7, 8, 13&lt;/sup&gt;&lt;/span&gt; Box 1 outlines key areas in which study-based and model-based economic evaluations differ.&lt;/p&gt;&lt;p&gt;We use an example of a randomised controlled trial (RCT) calculating the cost-effectiveness of a new blood pressure medicine compared with placebo to illustrate why modelled evaluations might be required. Firstly, the model can be used to synthesise evidence across multiple trials for decision making.&lt;span&gt;&lt;sup&gt;8&lt;/sup&gt;&lt;/span&gt; Whereas the RCT is only comparing the new medicine against the placebo, a modelled ","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":null,"pages":null},"PeriodicalIF":6.7,"publicationDate":"2024-08-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52409","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141913178","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Overcoming disparities in hepatocellular carcinoma outcomes in First Nations Australians: a strategic plan for action","authors":"Jessica Howell,&nbsp;Troy Combo,&nbsp;Paula Binks,&nbsp;Kylie Bragg,&nbsp;Sarah Bukulatjpi,&nbsp;Kirsty Campbell,&nbsp;Paul J Clark,&nbsp;Melissa Carroll,&nbsp;Jane Davies,&nbsp;Teresa de Santis,&nbsp;Kate R Muller,&nbsp;Bella Nguyen,&nbsp;John K Olynyk,&nbsp;Nicholas Shackel,&nbsp;Patricia C Valery,&nbsp;Alan J Wigg,&nbsp;Jacob George,&nbsp;Stuart K Roberts","doi":"10.5694/mja2.52395","DOIUrl":"10.5694/mja2.52395","url":null,"abstract":"&lt;p&gt;Every year, about 1800 Australians die of hepatocellular carcinoma (HCC), the most common type of primary liver cancer.&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;Aboriginal and Torres Strait Islander peoples of Australia (hereon respectfully referred to as First Nations Australians) are 2.5 times more likely to develop HCC and 1.4 times more likely to die from HCC than non-Indigenous Australians.&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;First Nations Australians with HCC have a 9% five-year survival rate compared with 23% for non-Indigenous Australians,&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; and are half as likely to be diagnosed with early-stage HCC and receive curative therapy.&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; This is driven by First Nations Australians being adversely affected by social, cultural and commercial determinants of health stemming from colonisation, racism and remoteness.&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;Chronic liver disease is the key cause of HCC and most chronic liver disease is preventable and treatable.&lt;span&gt;&lt;sup&gt;4, 5&lt;/sup&gt;&lt;/span&gt; First Nations Australians shoulder a disproportionate burden of chronic liver disease (Box 1).&lt;span&gt;&lt;sup&gt;6&lt;/sup&gt;&lt;/span&gt; Alcohol-related liver disease is a leading cause of HCC in all Australians, including First Nations Australians.&lt;span&gt;&lt;sup&gt;2, 7, 8&lt;/sup&gt;&lt;/span&gt; The prevalence of hepatitis B and C is two- to three-fold higher in First Nations Australians compared with non-Indigenous Australians.&lt;span&gt;&lt;sup&gt;2, 5&lt;/sup&gt;&lt;/span&gt; The most prevalent hepatitis B genotype in remote First Nations communities (genotype C4) is associated with more aggressive liver disease and increased HCC risk compared with other genotypes.&lt;span&gt;&lt;sup&gt;9, 10&lt;/sup&gt;&lt;/span&gt; Obesity and type 2 diabetes, both leading risk factors for metabolic-associated fatty liver disease, are twice as common in First Nations Australians than in non-Indigenous Australians.&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt; Importantly, First Nations Australians are more likely to have multiple cofactors driving liver injury,&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; warranting a multipronged approach to HCC prevention.&lt;/p&gt;&lt;p&gt;The two lead authors of this article, one First Nations Australian and one non-Indigenous Australian, established a nationally representative, diverse group of four First Nations Australian and 14 non-Indigenous Australian clinical and research leaders in the fields of HCC and chronic liver disease for the project. All authors have expertise in the provision of regional or remote models of HCC or chronic liver disease care, or both. First, an initial two-hour virtual meeting was held, where authors shared their thoughts and responses to two main topics: i) identifying unmet needs in prevention, diagnosis and treatment of HCC in First Nations Australians; and ii) identifying opportunities to address these unmet needs. All authors shared key evidence and their experiences and perspectives, representing the differing epidemiology, health resourcing, policy and legislative contexts across all Australian states and ","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":null,"pages":null},"PeriodicalIF":6.7,"publicationDate":"2024-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52395","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141897765","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}