Medical Journal of Australia最新文献

{"title":"Hepatocellular carcinoma surveillance in Australia: current and future perspectives","authors":"Samuel Hui","doi":"10.5694/mja2.52442","DOIUrl":"10.5694/mja2.52442","url":null,"abstract":"<p><b><i><span>In reply</span></i></b>: On behalf of my co-authors, I thank Braillon for their interest in our article.<span>¹</span> As highlighted by Braillon,<span>²</span> we accept there are some methodological limitations in the 2004 trial that investigated hepatocellular carcinoma (HCC) surveillance in Chinese hepatitis B patients with or without cirrhosis.<span>³</span> Braillon also refers to an additional negative trial for HCC surveillance. We assume this is in reference to the study by Chen and colleagues, which found surveillance resulted in earlier HCC diagnosis but without a reduction in overall mortality.<span>⁴</span> However, this trial was based on α-fetoprotein-only screening in Chinese hepatitis B patients between 1989 and 1995. These results cannot be generalised to modern clinical practice, given the considerable paradigm shift in surveillance, diagnosis and treatment over the past three decades.</p><p>In the absence of additional randomised trials, Braillon has shown that there remains some debate about the overall value of HCC surveillance. Further randomised trials are, however, unlikely to be practical or ethically feasible, given surveillance is a well established standard of care worldwide. A systematic review of contemporary observational data has found that HCC surveillance in cirrhotic patients results in early detection and improved survival due to curative treatment receipt, although the incidence and magnitude of surveillance-related harm is less well studied.<span>⁵</span></p><p>Given HCC surveillance is an established standard of care in high risk patients, we feel there is merit in a centralised surveillance program. Beyond improving access and uptake, centralisation will provide high quality prospective data that can assess the real-world benefit and harms of surveillance in Australia.</p><p>HCC is an emerging and costly public health problem in many Western countries that remains under-recognised. An important tenet of public health is the prioritisation of preventive care. In the case of HCC, we argue that an increased focus on its primary and secondary prevention presents the greatest opportunity for improving outcomes for this devastating disease.</p><p>No relevant disclosures.</p>","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"221 7","pages":"397"},"PeriodicalIF":6.7,"publicationDate":"2024-09-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52442","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142154499","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":"Pharmaceuticals in pregnancy: a multifaceted challenge in Australia","authors":"Stefan C Kane,&nbsp;Renuka Shanmugalingam,&nbsp;Amanda Henry","doi":"10.5694/mja2.52421","DOIUrl":"10.5694/mja2.52421","url":null,"abstract":"&lt;p&gt;Recent supply constraints for labetalol, immediate-release nifedipine and misoprostol tablets in Australia have highlighted pregnant women's vulnerability to critical medication supply disruptions, and underscored the broader structural disadvantage this population faces in accessing effective, evidence-based pharmaceutical agents. In this perspective article, we summarise key challenges underpinning this disadvantage and propose some solutions.&lt;/p&gt;&lt;p&gt;Drug companies and regulatory authorities worldwide have demonstrated a longstanding reluctance to study the effects of medications in pregnancy and women of reproductive age. Consequently, these women are significantly under-represented in pharmacological clinical trials.&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt; The thalidomide tragedy exemplifies the capacity for medications to cause birth defects. However, not developing new agents to treat medical conditions in pregnancy also causes harm by denying pregnant women pharmacotherapeutic advances enjoyed by other populations.&lt;/p&gt;&lt;p&gt;The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic reinforced this disadvantage: despite their greater risk of coronavirus disease 2019 (COVID-19)-related morbidity and mortality, pregnant women were systematically excluded from trials of vaccines and medical therapies,&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; resulting in fewer therapeutic options for this more vulnerable group. Conversely, a recent trial of maternal sildenafil therapy for fetal growth restriction (FGR) highlights the importance of research in guiding evidence-based perinatal practice.&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt; In the absence of an alternative effective treatment, and given the biological plausibility of benefit, sildenafil was used off-label for FGR, but the STRIDER trial identified a potential excess risk of fatal neonatal persistent pulmonary hypertension, without FGR survival benefit. Sildenafil use in FGR thus cannot be justified.&lt;span&gt;&lt;sup&gt;4&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;Indemnity costs and medicolegal concerns are only partially responsible for the reluctance to include pregnant women in therapeutic trials.&lt;span&gt;&lt;sup&gt;5&lt;/sup&gt;&lt;/span&gt; These considerations need to be reframed with reference to the inequity and risks of not including them.&lt;span&gt;&lt;sup&gt;6&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;We have a narrow spectrum of medications known to be safe and efficacious for use in pregnancy. These medications tend to be old, off-patent, and — in Australia — are often used off-label, as sponsoring pharmaceutical companies have not sought to have them registered for treatment of pregnancy-specific conditions. For example, in contrast to the more than 50 antihypertensive agents available to the non-pregnant population, the &lt;i&gt;Hypertension in pregnancy guideline 2023&lt;/i&gt;,&lt;span&gt;&lt;sup&gt;7&lt;/sup&gt;&lt;/span&gt; published by the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) and endorsed by the National Health and Medical Research Council (NHMRC), identifies only six medications with adequate safe","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"221 7","pages":"357-359"},"PeriodicalIF":6.7,"publicationDate":"2024-09-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52421","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142154501","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 rise in Mycoplasma pneumoniae respiratory infections in Victoria in late 2023 and early 2024 detected at two major testing laboratories","authors":"Maryza Graham,&nbsp;Thomas Tran,&nbsp;Changxu Zhang,&nbsp;Michelle Sam,&nbsp;Andrew Daley,&nbsp;Kathy Jackson,&nbsp;Chuan Kok Lim","doi":"10.5694/mja2.52433","DOIUrl":"10.5694/mja2.52433","url":null,"abstract":"&lt;p&gt;In November 2023, the World Health Organization noted that the numbers of outpatient consultations and hospital admissions for children with pneumonia caused by &lt;i&gt;Mycoplasma pneumoniae&lt;/i&gt; had increased in China since May 2023.&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt; In Denmark, a surge in &lt;i&gt;M. pneumoniae&lt;/i&gt; infections since October 2023 was reported, most in children or adolescents, but the impact on hospital capacity was limited; 446 of 3195 people (14%), primarily adults, required hospitalisation.&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;The most frequent manifestation of &lt;i&gt;M. pneumoniae&lt;/i&gt; infection in school-aged children, pneumonia, is generally mild. However, people of all ages can require hospitalisation because of severe community-acquired pneumonia (CAP) or extrapulmonary manifestations (including haemolysis and central nervous system disease).&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt; &lt;i&gt;M. pneumoniae&lt;/i&gt; is the most frequently detected bacterial pathogen in children hospitalised with CAP.&lt;span&gt;&lt;sup&gt;4&lt;/sup&gt;&lt;/span&gt; Infections are most frequent during summer and early autumn, but can develop at any time of year. The cumulative attack rate in families approaches 90%, and immunity is not long lasting.&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; &lt;i&gt;M. pneumoniae&lt;/i&gt; is resistant to β-lactam antibiotics, the mainstay of the empiric treatment of CAP. Recommended treatments for &lt;i&gt;M. pneumoniae&lt;/i&gt; include macrolide, tetracycline, and fluoroquinolone antibiotics, the prescribing of which requires clinical suspicion of this infection.&lt;/p&gt;&lt;p&gt;We reviewed the results of polymerase chain reaction (PCR) testing for &lt;i&gt;M. pneumoniae&lt;/i&gt; in the laboratory information systems of the Victorian Infectious Diseases Reference Laboratory (VIDRL; 1 January 2016 – 30 April 2024) and the Royal Children's Hospital (RCH; 1 January 2018 – 31 January 2024). At VIDRL, only samples for which &lt;i&gt;M. pneumoniae&lt;/i&gt; testing is specifically requested by the ordering clinician are tested (targeted testing). At RCH, targeted testing was undertaken prior to 2020; from January 2020, a syndromic multiplex PCR panel was used that included &lt;i&gt;M. pneumoniae&lt;/i&gt; targets (Respiratory Pathogens 16-well REF 20620; AusDiagnostics), and all samples submitted for respiratory pathogen testing were therefore tested for &lt;i&gt;M. pneumoniae&lt;/i&gt; (untargeted testing). Reporting by VIDRL of information on currently circulating pathogens, including outbreak or transmission investigations, is approved by the Office for Research Ethics and Governance of the Royal Melbourne Hospital (QA2022085); the analysis of RCH data for public health surveillance has local governance approval from the hospital legal services and human research ethics committee.&lt;/p&gt;&lt;p&gt;The &lt;i&gt;M. pneumoniae&lt;/i&gt; positivity rate at RCH was 4% (five of 124 samples) in 2018 and 8% (12 of 148 samples) in 2019 (targeted testing). At VIDRL, 5.9% (five of 85 samples) were positive in 2016; during 2016–2022 the positivity rate was 1.3% (15 of 1148 samples; targeted testing). Three of 14 837 R","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"221 8","pages":"436-437"},"PeriodicalIF":6.7,"publicationDate":"2024-09-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52433","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142140492","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 evidence-based skin checks","authors":"Linda K Martin,&nbsp;Pascale Guitera,&nbsp;Georgina V Long,&nbsp;Richard A Scolyer,&nbsp;Anne E Cust","doi":"10.5694/mja2.52443","DOIUrl":"10.5694/mja2.52443","url":null,"abstract":"&lt;p&gt;Melanoma is often referred to as Australia's national cancer, with the highest incidence per capita in the world due to the combination of high solar ultraviolet radiation levels, a temperate climate, outdoor lifestyle and genetically susceptible population.&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt; Melanoma is our third most common invasive cancer, and two-thirds of Australians will be diagnosed with keratinocytic tumours (including basal cell and squamous cell carcinomas).&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; Despite advances in treatment and improved survival over the past decade, one Australian dies about every six hours from melanoma.&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;Routine skin checks occur widely in Australia, with about one-third of Australian adults aged 45–69 years reporting having a whole-body skin check annually.&lt;span&gt;&lt;sup&gt;4&lt;/sup&gt;&lt;/span&gt; This form of ad-hoc screening is contrary to national and international recommendations, with both the Australian Government Standing Committee on Screening&lt;span&gt;&lt;sup&gt;5&lt;/sup&gt;&lt;/span&gt; and United States Preventive Services Taskforce&lt;span&gt;&lt;sup&gt;6&lt;/sup&gt;&lt;/span&gt; concluding insufficient information on the benefits and harms of skin cancer screening, and lack of data on cost-effectiveness. Herein, we discuss the need for evidence-based approaches to skin cancer detection in Australia. Risk factors and diagnostic techniques for melanoma and keratinocyte carcinoma overlap. This perspective article focuses on melanoma, which is most likely to be associated with mortality, and its detection and cost benefits from an organised screening program.&lt;/p&gt;&lt;p&gt;“Population screening” refers to an organised program to identify disease in asymptomatic populations.&lt;span&gt;&lt;sup&gt;5&lt;/sup&gt;&lt;/span&gt; Australian clinical practice guidelines recommend “opportunistic screening”, that is, patient-driven or clinician-initiated skin checks occurring outside an organised program, for patients at increased risk of melanoma, and six- to 12-monthly skin checks for anyone who has ever had a melanoma (targeted screening).&lt;span&gt;&lt;sup&gt;7&lt;/sup&gt;&lt;/span&gt; Detection and treatment of melanoma at an early stage is associated with an excellent prognosis, and increased mortality has been demonstrated with each 0.2 mm increment in Breslow thickness at diagnosis.&lt;span&gt;&lt;sup&gt;8&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;Skin cancer is Australia's most expensive cancer, with direct costs to the health care system of almost $2 billion per year.&lt;span&gt;&lt;sup&gt;9&lt;/sup&gt;&lt;/span&gt; The additional cost of skin checks that do not result in a diagnosis of skin cancer is difficult to accurately quantify, as there is no Medicare item or process to collect these data. Current reimbursement models reward high patient volume and high biopsy rates, and community fear of cancer and clinician fear of error can also drive over-servicing. The potential non-financial costs of skin checks include patient anxiety, overdiagnosis and surgical burden.&lt;span&gt;&lt;sup&gt;10&lt;/sup&gt;&lt;/span&gt; Increasing government spending on skin checks and skin cancer treatments may ","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"221 8","pages":"407-409"},"PeriodicalIF":6.7,"publicationDate":"2024-09-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52443","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142140493","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":"Updating the diagnosis and management of iron deficiency in the era of routine ferritin testing of blood donors by Australian Red Cross Lifeblood","authors":"Gary D Zhang,&nbsp;Daniel Johnstone,&nbsp;Michael F Leahy,&nbsp;John K Olynyk","doi":"10.5694/mja2.52429","DOIUrl":"10.5694/mja2.52429","url":null,"abstract":"&lt;p&gt;Iron deficiency is the most common micronutrient deficiency worldwide&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt; and the predominant cause of anaemia, which affects one-quarter of the global population.&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;In Australia, 22.3% of women have depleted iron stores (serum ferritin level &lt; 30 μg/L), with pre-menopausal women disproportionately affected.&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt; In contrast, 3.5% of men are iron deficient.&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;The Australian Red Cross Lifeblood implemented routine ferritin level testing in August 2023 for new whole blood donors (105 069 in 2023),&lt;span&gt;&lt;sup&gt;4&lt;/sup&gt;&lt;/span&gt; with expanded testing to include returning blood donors in 2024.&lt;span&gt;&lt;sup&gt;5&lt;/sup&gt;&lt;/span&gt; Donors are formally advised if their ferritin result is outside the reference intervals of 15–400 μg/L for female donors and 30–500 μg/L for male donors.&lt;span&gt;&lt;sup&gt;5&lt;/sup&gt;&lt;/span&gt; This will identify a considerable number of iron deficient adults who will be directed to their primary care physician for management. In the context of this policy change and implications for primary care, this article provides a guide for investigating and managing absolute iron deficiency.&lt;/p&gt;&lt;p&gt;Iron stores inadequate to meet the demands of the body result in absolute iron deficiency, which is associated with a compensatory reduction in serum hepcidin concentration to stimulate an increase in gastrointestinal iron absorption and restore homeostasis.&lt;span&gt;&lt;sup&gt;6-8&lt;/sup&gt;&lt;/span&gt; Functional iron deficiency occurs when relatively normal iron stores are unable to be released for physiological requirements due to inappropriately elevated serum hepcidin levels, as may occur in chronic inflammatory conditions, including obesity, chronic disease and neoplasia.&lt;span&gt;&lt;sup&gt;6-8&lt;/sup&gt;&lt;/span&gt; Absolute and functional iron deficiency can also co-exist.&lt;span&gt;&lt;sup&gt;7&lt;/sup&gt;&lt;/span&gt; A ferritin level below the reference interval should always be interpreted as absolute iron deficiency.&lt;/p&gt;&lt;p&gt;The diagnosis of iron deficiency is based on routinely available blood biomarkers as described in Box 1. Serum ferritin level cut-offs to diagnose iron deficiency vary considerably,&lt;span&gt;&lt;sup&gt;9&lt;/sup&gt;&lt;/span&gt; from less than 15 μg/L used by the World Health Organization,&lt;span&gt;&lt;sup&gt;10&lt;/sup&gt;&lt;/span&gt; which predicts absent iron stores with very high specificity,&lt;span&gt;&lt;sup&gt;7&lt;/sup&gt;&lt;/span&gt; to less than 30 μg/L commonly used in Australia.&lt;span&gt;&lt;sup&gt;7, 8, 11, 12&lt;/sup&gt;&lt;/span&gt; Although the sex-based cut-offs adopted by the Australian Red Cross Lifeblood were reportedly derived from the Royal College of Pathologists of Australasia,&lt;span&gt;&lt;sup&gt;12&lt;/sup&gt;&lt;/span&gt; there is significant concern regarding inequalities using unconventional sex-based cut-offs, with underdiagnosis and undertreatment of iron deficient women. As an acute-phase reactant, ferritin may be falsely normal or elevated in iron deficient individuals when there is concurrent inflammation, obesity, steatotic liver disease, malignancy or other chronic dise","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"221 7","pages":"360-364"},"PeriodicalIF":6.7,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52429","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142126132","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":"Cost barriers to medication access in Australia: an analysis of the Patient Experience Survey in context","authors":"Narcyz Ghinea","doi":"10.5694/mja2.52427","DOIUrl":"10.5694/mja2.52427","url":null,"abstract":"&lt;p&gt;In November 2023, the Australian Bureau of Statistics (ABS) released its 2022–23 Patient Experience Survey data.&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt; This latest release shows that many Australians struggle to afford the medicines they need and that cost barriers to access have increased compared with the previous year.&lt;/p&gt;&lt;p&gt;Women, younger people and those in poorer health are particularly affected. The data show that 9.4% of women compared with 5.5% of men reported cost-related non-adherence to medications (medication-CRNA) (ie, delaying or not filling scripts due to cost) prescribed by their general practitioner in the previous 12 months.&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; The proportion increases for younger women to 14.7% for 15–24-year-olds and to 13% for 25–34-year-olds (Box 1). However, considering that 8.4% of women (and as high as 11.3% for women aged 25–34 years) at least once delayed seeing or did not see a general practitioner,&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; and 12.2% (and as high as 20.3% for 25–34-year-olds) at least once delayed or did not see a specialist due to cost,&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt; the proportion of women directly or indirectly affected by medication-CRNA would be even higher.&lt;/p&gt;&lt;p&gt;Younger Australians are more likely to experience cost barriers to care than older Australians. A 25–34-year-old is 2.7 times more likely to experience medication-CRNA than a 75–84-year-old, 3.1 times more likely to delay visiting or not visit a general practitioner due to cost,&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; and 3.8 times more likely to delay visiting or not visit a specialist due to cost.&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt; For women, the discrepancy is much more pronounced, with 25–34-year-olds 3.5 times more likely to experience medication-CRNA than 75–84-year-olds, 3.8 times more likely to delay visiting or not visit a general practitioner, and 4.8 times more likely to delay visiting or not visit a specialist due to cost.&lt;/p&gt;&lt;p&gt;Health status also plays an important part, with 15% of individuals in fair or poor health experiencing medication-CRNA (2.3 times higher than those in good health) and 11.8% delay visiting or not visit a general practitioner due to cost (1.8 times higher).&lt;span&gt;&lt;sup&gt;4&lt;/sup&gt;&lt;/span&gt; For specialist visits the discrepancy was not as stark.&lt;span&gt;&lt;sup&gt;5&lt;/sup&gt;&lt;/span&gt; The most socio-economically disadvantaged people were also almost twice as likely to delay or not seek treatment than the most advantaged (Box 2).&lt;span&gt;&lt;sup&gt;4&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;The &lt;i&gt;de facto&lt;/i&gt; rate of medication-CRNA is necessarily higher than what is reported in the ABS's survey. Their data are collected in the context of general practice visits only, so they would not include medicines prescribed by specialists. This is a significant lacuna since 42.2% of those surveyed needed to see a specialist,&lt;span&gt;&lt;sup&gt;6&lt;/sup&gt;&lt;/span&gt; and it is reasonable to assume many of these patients would be prescribed some medication. The Australians that miss out on seeing a general practitioner or specialist du","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"221 8","pages":"414-416"},"PeriodicalIF":6.7,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52427","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142126131","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":"Summary of the 2023 international evidence-based guideline for the assessment and management of polycystic ovary syndrome: an Australian perspective","authors":"Helena J Teede,&nbsp;Aya Mousa,&nbsp;Chau T Tay,&nbsp;Michael F Costello,&nbsp;Leah Brennan,&nbsp;Robert J Norman,&nbsp;Alexia S Pena,&nbsp;Jacqueline A Boyle,&nbsp;Anju Joham,&nbsp;Lorna Berry,&nbsp;Lisa Moran","doi":"10.5694/mja2.52432","DOIUrl":"10.5694/mja2.52432","url":null,"abstract":"&lt;div&gt;\u0000 \u0000 \u0000 &lt;section&gt;\u0000 \u0000 &lt;h3&gt; Introduction&lt;/h3&gt;\u0000 \u0000 &lt;p&gt;The Australian-led &lt;i&gt;2023 International evidence-based guideline for the assessment and management of polycystic ovary syndrome&lt;/i&gt; was based on best available evidence, clinical expertise and consumer preference. It followed best practice, involved extensive evidence synthesis and applied relevant frameworks across evidence quality, feasibility, acceptability, cost and implementation. Thirty-nine societies and organisations covering 71 countries were engaged. The evidence in the assessment and management of polycystic ovary syndrome (PCOS) has generally improved in the past five years, but remains of low to moderate quality. The technical evidence report, 52 systematic reviews and analyses (approximately 6000 pages) underpin 77 evidence-based and 54 consensus recommendations, with 123 practice points.&lt;/p&gt;\u0000 &lt;/section&gt;\u0000 \u0000 &lt;section&gt;\u0000 \u0000 &lt;h3&gt; Main recommendations&lt;/h3&gt;\u0000 \u0000 &lt;div&gt;Changes include:\u0000\u0000 &lt;ul&gt;\u0000 \u0000 &lt;li&gt;refinement of individual diagnostic criteria, a simplified diagnostic algorithm and inclusion of anti-Müllerian hormone levels as an alternative to ultrasound in adults only, and differentiation of adolescent and adult criteria;&lt;/li&gt;\u0000 \u0000 &lt;li&gt;strengthening the recognition of broad features of PCOS including metabolic effects, cardiovascular disease, dermatological symptoms, sleep apnoea, a high prevalence of psychological features and a high risk of adverse pregnancy outcomes;&lt;/li&gt;\u0000 \u0000 &lt;li&gt;emphasising the poorly recognised, diverse burden of disease, the vital need for greater health professional education, evidence-based patient information, improved models of care, shared decision making and research efforts to improve patient experience;&lt;/li&gt;\u0000 \u0000 &lt;li&gt;maintained emphasis on healthy lifestyle, emotional wellbeing and quality of life, with awareness and consideration of weight stigma; and&lt;/li&gt;\u0000 \u0000 &lt;li&gt;emphasising evidence-based medical therapy and cheaper and safer fertility management.&lt;/li&gt;\u0000 &lt;/ul&gt;\u0000 &lt;/div&gt;\u0000 &lt;/section&gt;\u0000 \u0000 &lt;section&gt;\u0000 \u0000 &lt;h3&gt; Changes in management as a result of this guideline&lt;/h3&gt;\u0000 \u0000 &lt;p&gt;The 2023 guideline is approved by the National Health and Medical Research Council and provides clinicians and patients with clear advice on best practice in a common and neglected condition, based on the best available evidence, expert multidisciplinary input and consumer preferences. It provides vital, extensive patient and provider resources to enhance evidence-based care.&lt;/p&gt;\u0000 ","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"221 7","pages":"389-395"},"PeriodicalIF":6.7,"publicationDate":"2024-09-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52432","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142120210","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":"What is behind the declining incidence of melanoma in younger Australians?","authors":"Anne E Cust,&nbsp;Richard A Scolyer AO,&nbsp;Georgina V Long AO","doi":"10.5694/mja2.52411","DOIUrl":"10.5694/mja2.52411","url":null,"abstract":"&lt;p&gt;Australia is globally lauded for its leadership in preventing skin cancer, predominantly caused by ultraviolet radiation from the sun, and the impact of its national and state-based public education campaigns, including the iconic Slip! Slap! Slop! (Seek! Slide!) campaign&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt; and others focused on changing attitudes to tanning and sun protection behaviours, particularly among children and young adults.&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; These campaigns are recognised as key factors in the gradual reduction in the incidence of melanoma in people under the age of 30 years in Australia over the past 25 years,&lt;span&gt;&lt;sup&gt;1, 3&lt;/sup&gt;&lt;/span&gt; whereas melanoma incidence continues to increase among older people in Australia and in all age groups in most other countries.&lt;span&gt;&lt;sup&gt;3, 4&lt;/sup&gt;&lt;/span&gt; In Australia, high sun exposure is a more costly risk factor than tobacco use with respect to health system expenditure on cancer treatment.&lt;span&gt;&lt;sup&gt;5&lt;/sup&gt;&lt;/span&gt; Government investment in skin cancer prevention, at a tiny fraction of the cost of skin cancer treatment, provides about three times return on investment, and is therefore considered excellent value for money.&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;It is important that high quality, robust evidence guides health policy decisions. One methodological concern regarding the impact of skin cancer prevention campaigns is whether the decline in melanoma incidence among young Australians might be explained by an increasing proportion of migrants at low risk of melanoma, primarily because of their skin pigmentation, which would lower the overall risk in a population otherwise at high risk of melanoma.&lt;span&gt;&lt;sup&gt;6&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;This question is carefully addressed in the study by Whiteman and colleagues&lt;span&gt;&lt;sup&gt;7&lt;/sup&gt;&lt;/span&gt; reported in this issue of the &lt;i&gt;MJA&lt;/i&gt;. The authors used Australian census data on the reported ancestry of participants’ parents to classify people as being at high, moderate, or low risk of melanoma, and modelled invasive melanoma incidence trends for each of these ancestry groups during 2006–2021. Whiteman and his colleagues&lt;span&gt;&lt;sup&gt;7&lt;/sup&gt;&lt;/span&gt; found that the ancestry-based composition of the Australian population, and thus its melanoma risk profile, had indeed changed over time, with the proportion of people at high risk of melanoma (ie, people with two parents of European ancestry) falling from 85% in 2006 to 71% in 2021, with concomitant rises in the proportions for the moderate risk (from 5% to 10%) and low risk categories (from 10% to 19%). As more than 95% of diagnosed melanomas were in people in the high risk ancestry group, the changing population composition was indeed associated with a decline in melanoma incidence. However, it did not fully explain the falling melanoma incidence in younger age groups; when incidence patterns for the high risk ancestry group were examined separately to remove the confounding effect of population change, declines in incidenc","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"221 5","pages":"246-247"},"PeriodicalIF":6.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52411","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142108945","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":"Building and acting on the evidence for primary prevention of cancer","authors":"Elizabeth Zuccala","doi":"10.5694/mja2.52418","DOIUrl":"10.5694/mja2.52418","url":null,"abstract":"&lt;p&gt;Slip, Slop, Slap (and later, Seek, Slide)! Many readers will be familiar with this iconic Australian public health slogan that was launched in the early 1980s and became a core message of the Cancer Council's SunSmart program (https://cancer.org.au/cancer-information/causes-and-prevention/sun-safety/campaigns-and-events/slip-slop-slap-seek-slide). Australia has one of the highest rates of skin cancer in the world and over the past several decades has become a global leader in primary prevention and early detection efforts, with a particular focus on the use of media and advocacy campaigns aimed at improving the uptake of sun protection approaches. But teasing out the specific effects of public health campaigns is notoriously difficult. In the case of skin cancer, a major challenge facing researchers is how to measure the impacts of prevention efforts on disease burden in the context of rapidly changing population demographics, in particular those driven by migration.&lt;/p&gt;&lt;p&gt;In their research article published today in the &lt;i&gt;MJA&lt;/i&gt;, Whiteman and colleagues (https://doi.org/10.5694/mja2.52404) present findings of their modelling study that aimed to investigate the extent to which recent declines in melanoma incidence among young Australians might be explained by the increasing population proportion of migrants who are at low risk of melanoma owing to their ancestry. The study found that among people aged under 35 years, the incidence of melanoma is declining, including for people who have a high risk (European) ancestry. They conclude that “migration may have had an impact on the incidence of melanoma among younger Australians, but social changes may also have contributed to its decline”. Social and behavioural changes that might have contributed to reducing ultraviolet radiation exposure among young Australians could include improved uptake of protective measures such as using appropriate clothing, wearing sunscreen and seeking shade, as well as lifestyle trends that lead to people spending less time outdoors. Writing in a linked editorial, Cust and colleagues (https://doi.org/10.5694/mja2.52411) argue that despite these nuanced findings, “given that the incidence of melanoma and other skin cancers is highest in Australia, and that they are the most expensive cancers to treat, ongoing skin cancer prevention campaigns and other targeted initiatives will be essential for further reducing the burden of this highly preventable disease”.&lt;/p&gt;&lt;p&gt;Cancer prevention is covered again by a perspective (https://doi.org/10.5694/mja2.52395) on hepatocellular carcinoma (HCC) among First Nations Australians, who are 2.5 times more likely to develop HCC and 1.4 times more likely to die of HCC than non-Indigenous Australians. Although most chronic liver disease is preventable and/or treatable, it remains the main cause of HCC, with First Nations Australians more likely to have multiple cofactors driving liver injury. The two lead authors of this article, one Fir","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"221 5","pages":"229"},"PeriodicalIF":6.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52418","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142108942","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":"Changes in the incidence of melanoma in Australia, 2006–2021, by age group and ancestry: a modelling study","authors":"David C Whiteman,&nbsp;Rachel E Neale,&nbsp;Peter Baade,&nbsp;Catherine M Olsen,&nbsp;Nirmala Pandeya","doi":"10.5694/mja2.52404","DOIUrl":"10.5694/mja2.52404","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objectives</h3>\u0000 \u0000 <p>To estimate the incidence of melanoma in Australia among people with ancestries associated with low, moderate, or high risk of melanoma, by sex and 5-year age group; to establish whether age-specific incidence rates by ancestry risk group have changed over time.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study design</h3>\u0000 \u0000 <p>Modelling study; United States (SEER database) melanoma incidence rates for representative ancestral populations and Australian census data (2006, 2011, 2016, 2021) used to estimate Australian melanoma incidence rates by ancestry-based risk.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Setting, participants</h3>\u0000 \u0000 <p>Australia, 2006–2021.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Main outcome measures</h3>\u0000 \u0000 <p>Age-specific invasive melanoma incidence rates, and average annual percentage change (AAPC) in age-specific melanoma rates, by ancestry-based risk group, sex, and 5-year age group.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>The proportion of people in Australia who reported high risk (European) ancestry declined from 85.3% in 2006 to 71.1% in 2021. The estimated age-standardised melanoma incidence rate was higher for people with high risk ancestry (2021: males, 82.2 [95% confidence interval {CI}, 80.5–83.8] cases per 100 000 population; females, 58.5 [95% CI, 57.0–59.9] cases per 100 000 population) than for all Australians (males, 67.8 [95% CI, 66.5–69.2] cases per 100 000 population; females, 45.4 [95% CI, 44.3–46.5] cases per 100 000 population). AAPCs were consistently positive for Australians aged 50 years or older, both overall and for people with high risk ancestry, but were statistically significant only for some age groups beyond 65 years. AAPCs were negative for people aged 34 years or younger, but were generally not statistically significant.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Melanoma incidence has declined in some younger age groups in Australia, including among people with high risk ancestry. Social and behavioural changes over the same period that lead to lower levels of ultraviolet radiation exposure probably contributed to these changes.</p>\u0000 </section>\u0000 </div>","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"221 5","pages":"251-257"},"PeriodicalIF":6.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52404","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142108943","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}