Medical Journal of Australia最新文献

{"title":"Ethical challenges of multiple organ transplant in cystic fibrosis","authors":"Mark R Oliver, John Massie, Miranda Paraskeva, Avik Majumdar, Lynn H Gillam, Dominic JC Wilkinson","doi":"10.5694/mja2.52547","DOIUrl":"10.5694/mja2.52547","url":null,"abstract":"<p>Effective treatment in the form of cystic fibrosis transmembrane regulator (CFTR) modulator therapy targeting the most common gene mutations is now available for over 90% of people with cystic fibrosis over the age of 2 years. This treatment results in improvement of lung function and nutritional status.<span><sup>1</sup></span> However, it is not known whether these effects will be sustained or have a wider influence on the multiple organs affected by cystic fibrosis if introduced early in life. Hence, many Australian people with cystic fibrosis will continue to live with the possibility of organ failure, albeit fewer than in previous generations. There is agreement that single organ transplantation in a patient with organ failure is medically appropriate and ethically justifiable. However, cystic fibrosis can result in the insidious failure of several organs simultaneously, such that single organ transplant is neither possible nor life prolonging. In such circumstances, multiple organ transplant would be considered. However, there are several complex medical factors that transplant teams need to consider, such as feasibility (infrastructure and centralisation of services) and benefit to the patient (usefulness) along with the ethical consideration of organ rationing when donors are limited. Due to recent treatment improvements, the need for multiple organ transplants in people with cystic fibrosis is decreasing; however, we still need to ensure equity regarding decision making. In this article, we explore the ethical principles associated with multiple organ transplant in people with cystic fibrosis in the current setting, using a fictional patient representative of a typical patient with cystic fibrosis.</p><p>A referral is received from the local cystic fibrosis service for a 22-year-old man (Box 1) for consideration of a combined lung and liver transplant. He has a forced expiratory volume in one second (FEV<sub>1</sub>) of less than 30%, life-threatening haemoptysis and worsening nutrition despite full supplemental feeding. His genotype (<i>G543X</i> and <i>N1303K</i>) was not responsive to CFTR modulator therapy.<span><sup>2</sup></span> In addition, he has portal hypertension because of advanced cystic fibrosis-related liver disease and has suffered life-threatening variceal bleeding. He has read about multiple organ transplant in cystic fibrosis and has discussed this with his team, who agree that this is an option to explore, given a substantially diminished quality of life and poor survival with severe dual organ disease. But is it ethically appropriate to list him for transplantation?</p><p>Multiple organ transplant in people with cystic fibrosis has been accepted as a treatment option globally (North America, Europe, England, Australia and New Zealand) and increasing numbers are being performed.<span><sup>3-6</sup></span> Multiple organ transplant has been demonstrated to provide a significant advantage to recipients including sur","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"222 1","pages":"20-22"},"PeriodicalIF":6.7,"publicationDate":"2024-12-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52547","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142780617","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":"National Hypertension Taskforce of Australia: a roadmap to achieve 70% blood pressure control in Australia by 2030","authors":"Madeleine M Cosgrave,&nbsp;Catherine A Brumby,&nbsp;Matthew A Roberts,&nbsp;Lawrence P McMahon","doi":"10.5694/mja2.52553","DOIUrl":"10.5694/mja2.52553","url":null,"abstract":"<p><span>To the Editor:</span> It was most welcome to see hypertension receive due attention in the timely roadmap of the National Hypertension Taskforce of Australia.<span>¹</span> The authors described the pillars of “prevent”, “detect” and “treat effectively” and listed the appropriate high risk groups. However, one group, women with hypertensive disorders of pregnancy (HDP), was curiously omitted.</p><p>All women are screened for hypertension in pregnancy, and each year 5–10% are diagnosed with HDP. These women have a lifelong increased risk of cardiovascular disease (CVD). It is not merely a concern for older age groups. Disturbingly, there is a doubling in risk of cardiovascular events in the first ten years following pregnancy. The risk is multiplied by five times if the HDP was early onset.<span>²</span> The ramifications are often unrecognised as blood pressure usually normalises within weeks of delivery and the needs of the newborn quickly supersede those of the mother.</p><p>An additional concern is that many women are not aware of the elevated risks of HDP. A New South Wales survey of 105 women with prior HDP found that only 18 (17%) knew of their increased cardiovascular risk.<span>³</span> General practitioners need to be informed of their patient's HDP diagnosis to manage their long term cardiovascular risks. Lack of patient awareness and inaccurate or incomplete discharge summaries can hamper the general practitioner's awareness and subsequent treatment.</p><p>Women are already disadvantaged when it comes to cardiovascular health: appraisal of their risk factors is less likely, and prescription of evidence-based therapies is less common in young women (aged 35–54 years) compared with their male counterparts with the same risk of CVD.<span>⁴</span> It was heartening to see relevant information on HDP added to the Australian CVD Risk Calculator<span>⁵</span> in 2023, but there is a long way to go.</p><p>Pregnancy is an opportunity to detect, treat and educate women of childbearing age regarding hypertension. All women with HDP and their respective general practitioners should be informed of their diagnosis and increased CVD risk. In line with current national guidelines,<span>⁶</span> all women with HDP should have an annual review of blood pressure and cardiovascular risk factors to facilitate early detection and treatment of hypertension — Pillars B and C of the roadmap. For the National Hypertension Taskforce of Australia roadmap to achieve its goal, this at-risk group should be included in the roadmap.</p><p>No relevant disclosures.</p>","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"222 2","pages":"104"},"PeriodicalIF":6.7,"publicationDate":"2024-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52553","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142770174","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":"National Hypertension Taskforce of Australia: a roadmap to achieve 70% blood pressure control in Australia by 2030","authors":"Aletta E Schutte,&nbsp;Markus Schlaich","doi":"10.5694/mja2.52554","DOIUrl":"10.5694/mja2.52554","url":null,"abstract":"<p><b><i><span>In reply</span></i></b>: On behalf of the National Hypertension Taskforce of Australia, we welcome the above comment from Cosgrove and colleagues<span>¹</span> on our roadmap<span>²</span> and fully appreciate the importance of hypertensive disorders of pregnancy (HDP) as a high risk condition for future development of established hypertension and cardiovascular disease (CVD).<span>³</span> While not specifically mentioned as a high risk group in the roadmap, risk-based management of CVD is a critical component of the HEARTS package to be adopted and tailored to the Australian circumstances to diagnose and treat hypertension effectively, including HDP (Pillar C).<span>²</span> Team-based and patient-centred care is another essential aspect and will allow implementation of systematic blood pressure screening and monitoring, delivered by general practitioners, physicians and, importantly, by obstetricians, as mentioned in the roadmap (Pillar B).<span>²</span></p><p>Continuous monitoring of blood pressure postpartum seems particularly relevant in view of recent evidence indicating a 2.4-fold increased risk of hypertension ten years after the occurrence of HDP.<span>⁴</span> Indeed, observed differences in non-invasive measures of CVD risk were predominantly driven by the hypertension diagnosis, regardless of HDP history, suggesting that the known long term risk of CVD after HDP may primarily be a consequence of hypertension development and uncontrolled blood pressure levels.<span>⁴</span></p><p>Adding further to the complexity is the observation that both HDP and associated CVD disproportionally affect black women, as shown in an American study predominantly including women who self-identified as black. This highlights possible racial disparities<span>⁴</span> and the need for further research and exploration of the underlying mechanisms.</p><p>Another important group of patients not mentioned specifically in the roadmap is adolescents, a cohort frequently lost in transition from paediatric to adult physician care.<span>⁵</span> To remedy this, a call for Australian clinical practice guidelines for paediatric hypertension (including adolescents) has recently been published<span>⁶</span> and development is underway.</p><p>While it was beyond the scope of the roadmap to address specific aspects of all patient groups affected, the guidance provided in the document under the principal pillars of prevent, detect and treat effectively, combined with adequate and timely implementation of the required framework, should allow us to substantially improve blood pressure control rates for all Australians and curb the enormous burden of hypertension on our society.</p><p>No relevant disclosures.</p>","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"222 2","pages":"104-105"},"PeriodicalIF":6.7,"publicationDate":"2024-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52554","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142770306","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":"Intrinsic capacity and ageing well for Aboriginal people in remote Western Australia: a longitudinal cohort study","authors":"Zoë Hyde,&nbsp;Kate Smith,&nbsp;Roslyn Malay,&nbsp;Dina C LoGiudice,&nbsp;Dawn C Bessarab,&nbsp;David N Atkinson,&nbsp;Edward Strivens,&nbsp;Leon Flicker","doi":"10.5694/mja2.52544","DOIUrl":"10.5694/mja2.52544","url":null,"abstract":"&lt;div&gt;\u0000 \u0000 \u0000 &lt;section&gt;\u0000 \u0000 &lt;h3&gt; Objective&lt;/h3&gt;\u0000 \u0000 &lt;p&gt;To assess intrinsic capacity, an important component of ageing well, in older Aboriginal people living in remote Western Australia.&lt;/p&gt;\u0000 &lt;/section&gt;\u0000 \u0000 &lt;section&gt;\u0000 \u0000 &lt;h3&gt; Study design&lt;/h3&gt;\u0000 \u0000 &lt;p&gt;Longitudinal cohort study; secondary analysis of survey and clinical assessment data.&lt;/p&gt;\u0000 &lt;/section&gt;\u0000 \u0000 &lt;section&gt;\u0000 \u0000 &lt;h3&gt; Setting&lt;/h3&gt;\u0000 \u0000 &lt;p&gt;Kimberley region of Western Australia (six remote communities, and the town of Derby).&lt;/p&gt;\u0000 &lt;/section&gt;\u0000 \u0000 &lt;section&gt;\u0000 \u0000 &lt;h3&gt; Participants&lt;/h3&gt;\u0000 \u0000 &lt;p&gt;Aboriginal people aged 45 years or older, initially recruited 15 July 2004 – 17 November 2006.&lt;/p&gt;\u0000 &lt;/section&gt;\u0000 \u0000 &lt;section&gt;\u0000 \u0000 &lt;h3&gt; Main outcome measures&lt;/h3&gt;\u0000 \u0000 &lt;p&gt;Intrinsic capacity (assessed in each participant by questionnaire and review by a consultant specialist), overall and by domain, and presence of core activity limitations, at baseline and follow-up (8 February 2011 – 6 June 2013); risk of death by follow-up; preservation of intrinsic capacity at follow-up.&lt;/p&gt;\u0000 &lt;/section&gt;\u0000 \u0000 &lt;section&gt;\u0000 \u0000 &lt;h3&gt; Results&lt;/h3&gt;\u0000 \u0000 &lt;p&gt;The mean age of the 345 participants at baseline was 60.2 years (standard deviation [SD], 11.6 years; range, 45–96 years); 152 were men (44.1%) and 193 were women (55.9%). Intrinsic capacity was unimpaired in all five domains for 55 participants (15.9%; 95% confidence interval [CI], 12.4–20.2%). Capacity in the vitality domain was unimpaired in 325 respondents (94.2%), in the psychological/mood domain in 318 (92.2%), and in the cognition domain in 289 people (83.8%); the locomotion domain was unimpaired in 174 people (50.4%), and the sensory domain in 117 people (33.9%). The proportion of men with full capacity in all five domains (32 of 152, 21.1%) was larger than for women (23 of 193, 11.9%). Of the 274 people included in follow-up analyses, intrinsic capacity was lower than at baseline for 66 people (24.1%), it was unchanged or improved in 111 participants (40.5%; 95% CI, 34.8–46.5%), and 97 people had died (35.4%). Thirty-seven of the 177 surviving participants for whom complete data were available had full capacity in all domains (20.9%; 95% CI, 15.5–27.6%). After adjustment for age, the number of unimpaired intrinsic capacity domains at baseline was inversely associated with having a core activity limitation at baseline (per domain: adjusted prevalence ratio, 0.43; 95% CI, 0.34–0.55) and follow-up (adjusted risk ratio, 0.62; 95% CI, 0.44–0.88), and with risk of","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"222 1","pages":"38-46"},"PeriodicalIF":6.7,"publicationDate":"2024-12-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52544","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142769947","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":"Castleman disease following post-coronavirus disease 2019 multisystem inflammatory syndrome in adults","authors":"Katherine J Punshon,&nbsp;Anugrah Chrispal","doi":"10.5694/mja2.52546","DOIUrl":"10.5694/mja2.52546","url":null,"abstract":"&lt;p&gt;A 50-year-old man presented with one week of progressive dyspnoea, abdominal pain and malaise, together with one month of enlarging capillary haemangiomas. His medical history reported post-coronavirus disease 2019 (COVID-19) multisystem inflammatory syndrome in adults (MIS-A), diagnosed 18 months prior with dyspnoea and abdominal pain, and associated with progressive kidney injury, liver function derangements, pancytopenias and mediastinal lymphadenopathy. MIS-A was diagnosed clinically after non-diagnostic mediastinal lymph node and liver biopsies. He was treated with corticosteroids, which were weaned only five months before the current presentation.&lt;/p&gt;&lt;p&gt;On presentation, his vital signs and initial examination were unremarkable. Blood results showed anaemia, inflammation, acute kidney injury and cholestatic liver derangement (Box 1). A chest x-ray showed small bilateral pleural effusions, further evaluated with computed tomography pulmonary angiography, which revealed mediastinal and axillary adenopathy. Serological workup revealed unremarkable infectious, autoimmune and haematologic screens (Box 2).&lt;/p&gt;&lt;p&gt;A positron emission tomography scan showed innumerable mildly to moderately fludeoxyglucose (FDG)-avid enlarged and non-enlarged lymph nodes above and below the diaphragm, and increased splenic and bone marrow activity (Box 3). Biopsy samples were taken from the most FDG-avid axillary and mediastinal lymph nodes, but were non-diagnostic. The results from one biopsy showed non-caseating granulomas; however, results from the second biopsy did not. An excisional lymph node biopsy was subsequently taken, with the results meeting histopathologic criteria for Castleman disease (Box 4). These criteria included depleted germinal centres, concentric rimming of small B lymphocytes in a “onion skin” appearance, and vascularity with vessels extending into the germinal centre.&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;The patient was diagnosed with multicentric Castleman disease, and commenced on high dose prednisolone and interleukin-6 inhibitor siltuximab. At the time of writing, he was in incomplete remission.&lt;/p&gt;&lt;p&gt;The 50-year-old-patient presented with exuberant multisystem inflammation. With a history of MIS-A, a relapse was initially considered; however, there are no documented cases of relapsed MIS-A. Thus, alternative causes were considered, especially in the context of extensive lymphadenopathy.&lt;/p&gt;&lt;p&gt;Core lymph node biopsy results revealed non-caseating granulomas, initially suspicious of sarcoidosis. However, non-caseating granulomas may also indicate many viral, bacterial or fungal infections, vasculitides, occupational diseases and haematological disorders.&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; Core lymph node biopsies can provide definitive diagnosis in more than 92% of cases. However, they have an increased rate of incorrect and non-conclusive diagnosis compared to an excisional lymph node biopsy.&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt; Excisional lymph node biopsies shou","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"222 1","pages":"17-19"},"PeriodicalIF":6.7,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52546","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142769972","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":"Inclusivity in Australian population surveys: missed opportunities to understand the health experiences of culturally and linguistically diverse populations","authors":"Humaira Maheen,&nbsp;Tania King","doi":"10.5694/mja2.52545","DOIUrl":"10.5694/mja2.52545","url":null,"abstract":"&lt;p&gt;Population surveys are crucial to public health research, offering critical information on morbidity at a population level, health service use, and attitudes and intentions regarding health outcomes and behaviours. In Australia, population surveys are widely used to identify emerging health needs and their determinants and are vital in informing health policies and programs. Despite their geographic representation, these surveys often fail to adequately represent the diversity within Australia's culturally and linguistically diverse (CALD) populations. This impedes understanding of health patterning among these populations. It prevents the identification of unique disease patterns, predictive risk factors, preferences for engaging with health services, and barriers to care that these communities encounter,&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt; and potentially obscures our understanding of health inequalities among different groups.&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; In this perspective, we highlight the imperative for population surveys to improve their inclusivity and thereby enable more comprehensive understanding of the needs of CALD groups. We discuss the implications of the non-inclusiveness of CALD populations and propose a way forward to ensure better representation and inclusion in these surveys.&lt;/p&gt;&lt;p&gt;The term “CALD communities” is unique to the Australian context. In 1996, it was first used to describe the diversity within the Australian population, replacing the term “non-English speaking backgrounds”, which was criticised for being non-inclusive.&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt; The Australian Bureau of Statistics (ABS) defines the CALD population using a set of minimum core cultural and language indicators (four items) and 12 standard indicators (including the four core items) representing diversity within these groups (Box 1).&lt;span&gt;&lt;sup&gt;9&lt;/sup&gt;&lt;/span&gt; Most Australian surveys comply with the minimum core data, with very few reporting all 12 standard indicators, noting that some report “country of birth” and “language spoken at home” with aggregate, broad categories rather than specific countries or languages. English language proficiency and Indigenous status are part of the minimum core data reported in all surveys (Box 1).&lt;/p&gt;&lt;p&gt;There are two principal ways by which population surveys miss opportunities to adequately capture the experiences of CALD populations: (i) under-representation of vulnerable groups and (ii) overlooking critical diversity indicators. The lack of inclusion of CALD populations in clinical trials and other research designs has garnered significant attention in recent years.&lt;span&gt;&lt;sup&gt;10-12&lt;/sup&gt;&lt;/span&gt; Two studies&lt;span&gt;&lt;sup&gt;13, 14&lt;/sup&gt;&lt;/span&gt; shed light on how diverse population groups are often excluded in academic research at the design stage, and when these groups are sampled, analysis is rarely stratified by CALD groups to enable meaningful insights into the experiences of these groups. We argue that such issues extend to Australian ","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"222 1","pages":"13-16"},"PeriodicalIF":6.7,"publicationDate":"2024-11-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52545","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142751335","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":"Updated recommendations for warfarin reversal in the setting of four-factor prothrombin complex concentrate","authors":"Danielle Robinson,&nbsp;James McFadyen,&nbsp;Eileen Merriman,&nbsp;Chee Wee Tan,&nbsp;Ross Baker,&nbsp;Huyen Tran","doi":"10.5694/mja2.52538","DOIUrl":"10.5694/mja2.52538","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>Warfarin (vitamin K antagonist) remains an established anticoagulant for patients at high risk of arterial and venous thromboembolism. The prompt reversal of the anticoagulant effect of warfarin is necessary in the context of major bleeding or emergency surgery because of its extended inhibition of vitamin K-dependent coagulation factors for days. The mainstay of urgent warfarin reversal has been vitamin K administration, and infusion of a three-factor prothrombin complex concentrate (3FPCC) and the option for the addition of fresh frozen plasma as a source of factor VII. With the upcoming introduction in Australia and New Zealand of a four-factor prothrombin complex concentrate (4FPCC), which replaces all the vitamin K-dependent clotting factors, this article updates the previously published warfarin reversal guidelines.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Main recommendations</h3>\u0000 \u0000 <p>For urgent warfarin reversal, 4FPCC should be used instead of 3FPCC, using the same suggested dose. Vitamin K co-administration is still recommended for more sustained reversal.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Changes in management as a result of this statement</h3>\u0000 \u0000 <p>The use of 4FPCC for urgent warfarin reversal obviates the need for co-administration of fresh frozen plasma.</p>\u0000 </section>\u0000 </div>","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"222 1","pages":"49-51"},"PeriodicalIF":6.7,"publicationDate":"2024-11-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52538","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142716516","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":"Is the term bulk-billing still relevant in today's landscape of health policy reform?","authors":"Michael Wright,&nbsp;May Chin","doi":"10.5694/mja2.52543","DOIUrl":"10.5694/mja2.52543","url":null,"abstract":"&lt;p&gt;As Medicare enters its 40th year and we reflect on its achievements, it is timely to assess the usefulness and relevance of a term that is closely associated with it: bulk-billing.&lt;/p&gt;&lt;p&gt;The term bulk-billing originated when Medicare was first introduced in 1984, and it referred to the manual process where a medical practitioner would submit collected paper receipts in bulk to Medicare. Although the practice of physically sending bulk receipts to Medicare has long since disappeared, the term bulk-billing has persisted.&lt;/p&gt;&lt;p&gt;The state of the Australian health system looks very different now than it did 40 years ago when Medicare was first introduced. In that time, the term bulk-billing has become synonymous with marker of access to general practice and in the delivery of health care with zero cost to the patient. This is in part due to current and past governments using the bulk-billing rate as a political indicator of health policy successes and as an indictment by opposition parties on the government of the day's commitment to health care access and equity. For example, in 2021, the former Minister for Health, the Hon Greg Hunt, used bulk-billing rates to demonstrate the then Coalition government's firm commitment to Medicare, despite also being the government responsible for extending the freeze on the Medicare indexation.&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt; Similarly, the current Minister for Health, the Hon Mark Butler, also used increases in the bulk-billing rate as evidence of the success of the 2023 Budget initiatives to triple the bulk-billing incentives for Australians with concession cards and those aged under 16 years.&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;At the time of its introduction, Medicare was designed to ensure all Australians have access to affordable health care by subsidising 85% of the cost of general practice services, increasing to 100% in 2004. Since then, Medicare rebates have not kept pace with increasing inflation nor the costs of care. From 1995 to 2022, increases in Medicare rebates averaged just over 1.1% annually,&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt; compared with general inflation reaching up to 7.3% during the same period.&lt;span&gt;&lt;sup&gt;4&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;Although the bulk-billing rate has been used as metric for general practice access, there is no standardised definition or interpretation. The bulk-billing rate typically quoted by politicians reflects the reported percentage of subsidised services that are bulk billed — the &lt;i&gt;volume&lt;/i&gt; of bulk billed general practice services — and provides little insight into patient access to general practice.&lt;/p&gt;&lt;p&gt;Organisations such as Cubiko and Cleanbill have attempted to further interpret the bulk-billing rate with key differences. Cubiko, in their 2023 Touchstone report refers to the bulk-billing rate as “the percentage of invoices [that are bulk billed]” recognising that multiple Medicare services can be provided at one time distorting bulk-billing metrics.&lt;span&gt;&lt;sup&gt;5&lt;/sup&gt;&lt;/span&gt; Cubiko als","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"222 2","pages":"66-68"},"PeriodicalIF":6.7,"publicationDate":"2024-11-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52543","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142716512","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":"Disorders of gut–brain interaction, eating disorders and gastroparesis: a call for coordinated care and guidelines on nutrition support","authors":"Trina Kellar,&nbsp;Chamara Basnayake,&nbsp;Rebecca E Burgell,&nbsp;Michael Kamm,&nbsp;Hannah W Kim,&nbsp;Kate Lane,&nbsp;Kate Murphy,&nbsp;Nicholas J Talley","doi":"10.5694/mja2.52537","DOIUrl":"10.5694/mja2.52537","url":null,"abstract":"&lt;p&gt;Untangling the complex interplay between eating disorders, gut–brain disorders and motility disorders is challenging. Nationally and internationally, there has been a concerning increase in patients receiving artificial nutrition that may be unnecessary.&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt; This places patients at risk of iatrogenic harm and results in considerable economic burden to health services. There is a clear need for high quality research to guide care, but in its absence, now more than ever, we require a national treatment consensus to support clinicians working in this field. This article aims to highlight the current status, knowledge, and service limitations in treating this difficult cohort of patients, and make recommendations on future strategies within Australia to move forward for better patient outcomes.&lt;/p&gt;&lt;p&gt;Diagnostic labels applied to patients with postprandial pain, nausea, regurgitation and satiety limiting oral intake, vary considerably and are influenced by the specialty first encountered.&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; When a formal eating disorder diagnosis is made, gastrointestinal symptoms are accepted as secondary and may go untreated, leaving patients feeling invalidated and stigmatised. In contrast, patients presenting to gastroenterologists are more likely to receive a diagnosis of a disorder of gut–brain interaction (DGBI), such as irritable bowel syndrome (IBS), functional dyspepsia, chronic nausea vomiting syndrome or gastroparesis, and the eating disorder is overlooked. Once a diagnosis of motility disorder is applied, patients may identify strongly with this, and find it difficult to accept a diagnosis of a co-existing disorder of gut–brain interaction.&lt;/p&gt;&lt;p&gt;In the internet era, diagnoses are also influenced by unregulated health information and social media. In an attempt to understand their condition, patients may extensively research and invest in diagnoses that are incorrect. In an attempt to help their patients, clinicians may place too great an emphasis on overarching diagnoses that are not yet well understood (eg, mast cell activation syndrome, superior mesenteric artery syndrome, median arcuate ligament syndrome, hypermobility syndromes, postural orthostatic tachycardia and autonomic neuropathy). Some such diagnoses carry greater risk than others, for instance, there are no long term studies describing the clinical outcomes of surgical intervention for superior mesenteric artery syndrome or median arcuate ligament syndrome.&lt;/p&gt;&lt;p&gt;Critically, there is significant overlap between functional dyspepsia and chronic nausea vomiting syndrome, eating disorders and gastroparesis, regardless of the diagnostic label. There are currently no gastrointestinal investigations that can accurately separate these diagnoses. Indeed, it is possible that these conditions represent a spectrum that cannot be separated. For example, a large American prospective cohort study defined patients with the same symptom phenotype as having eithe","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"222 1","pages":"10-12"},"PeriodicalIF":6.7,"publicationDate":"2024-11-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52537","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142710502","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":"Towards a cure for long COVID: the strengthening case for persistently replicating SARS-CoV-2 as a driver of post-acute sequelae of COVID-19","authors":"Michelle JL Scoullar,&nbsp;Gabriela Khoury,&nbsp;Suman S Majumdar,&nbsp;Emma Tippett,&nbsp;Brendan S Crabb","doi":"10.5694/mja2.52517","DOIUrl":"10.5694/mja2.52517","url":null,"abstract":"&lt;p&gt;New insights into post-acute sequelae of coronavirus disease 2019 (PASC) or long COVID are emerging at great speed. Proposed mechanisms driving long COVID include the overlapping pathologies of immune and inflammatory dysregulation, microbiota dysbiosis, autoimmunity, endothelial dysfunction, abnormal neurological signalling, reactivation of endogenous herpesviruses, and persistence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).&lt;span&gt;&lt;sup&gt;1, 2&lt;/sup&gt;&lt;/span&gt; In this commentary, we describe some of these advances that indicate that long COVID may be driven by “long infection” and that persistent replicating SARS-CoV-2 may be the potentially mechanistically unifying driver for long COVID.&lt;/p&gt;&lt;p&gt;The United Kingdom (UK)&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt; and United States (US)&lt;span&gt;&lt;sup&gt;4&lt;/sup&gt;&lt;/span&gt; report that substantial proportions of their populations are affected by long COVID, and that these proportions have remained at similar or slightly elevated levels across the past year at around 3% in the UK, and 5.5% in the US. Factors likely driving this include the chronic nature of long COVID lasting several years in some, and the high number of ongoing infections and cumulative risk of long COVID with each infection,&lt;span&gt;&lt;sup&gt;5&lt;/sup&gt;&lt;/span&gt; even in highly vaccinated populations.&lt;span&gt;&lt;sup&gt;6&lt;/sup&gt;&lt;/span&gt; Individuals in low income countries also suffer a substantial, albeit less defined, long COVID burden.&lt;span&gt;&lt;sup&gt;7&lt;/sup&gt;&lt;/span&gt; Moreover, children are not spared,&lt;span&gt;&lt;sup&gt;8&lt;/sup&gt;&lt;/span&gt; with up to 5.8 million children estimated to have the disease in the US alone.&lt;span&gt;&lt;sup&gt;8&lt;/sup&gt;&lt;/span&gt; Using the UK and US figures to extrapolate the global prevalence of long COVID generates an estimate of several hundred million people with long COVID.&lt;/p&gt;&lt;p&gt;Common symptoms of long COVID include fatigue, brain fog and post-exertional malaise (PEM).&lt;span&gt;&lt;sup&gt;9&lt;/sup&gt;&lt;/span&gt; Long COVID is also highly associated with cardiovascular and autonomic dysfunction, particularly postural autonomic tachycardia syndrome (POTS) and a vast range of fluctuating symptoms,&lt;span&gt;&lt;sup&gt;5, 10&lt;/sup&gt;&lt;/span&gt; and shares overlapping symptomology with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). These symptoms can make undertaking typical activities extremely difficult with implications for workforce access and productivity, and school participation. There are several definitions of long COVID and this creates a barrier to timely diagnosis and access to care, in addition to the research and epidemiological challenges this creates. Clearer terminology for the distinction between increased risk of specific health conditions (eg, type 1 diabetes, cardiac events) and the syndrome of long COVID is also important.&lt;/p&gt;&lt;p&gt;The long term impacts of COVID on the brain are becoming clearer. Sustained inflammation disrupting the blood–brain barrier has been shown to be a key mechanism driving the cognitive and related symptoms in long COVID.&lt;span&gt;&lt;sup&gt;11&lt;/sup&gt;&lt;/span&gt; A recent","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"221 11","pages":"587-590"},"PeriodicalIF":6.7,"publicationDate":"2024-11-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11625527/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142710509","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}