The MJA 2017: the year in review, and looking forward to 2018

In multicultural Australia, whatever your religious beliefs or cultural background, we celebrate together the summer holiday period and our shared values of family and community. On behalf of the entire MJA team, we welcome you to the 2017 Christmas issue of the Journal, a tradition in which we strive to amuse and entertain our readers over the holiday season.

Santa Claus, the Tooth Fairy, and a rakghoul walked into a bar …

“Well, who would have imagined that!” mused the barman. We were pleased to have again received a superb collection of amusing and entertaining articles for this issue, and congratulate all authors for their contributions. We wish we had room to publish all the excellent material we receive, but hope you will enjoy what we have selected for you after our standard rigorous editorial process. This year’s Christmas hamper for the best entry will be travelling to Raphael Patcas and his co-authors in Zurich, who taught us that the Tooth Fairy is very generous in a city more famous for its gnomes (page 482). Deciding the runners-up proved difficult, but in the end we congratulate Shian Miller and Tamara Johnson (Brisbane and Sydney) for their warning to Santa Claus (page 487), and Dimitrios-Giorgios Kontopoulos and colleagues (Ascot and Athens) for their warning to us all (page 490)!

The MJA in numbers

The MJA has a long and proud tradition. For more than a century, the Journal has published outstanding research and excellent editorials, letters to the editor, review articles, and, more recently, meta-analyses and evidence-based guidelines. The MJA is a widely read, top tier general medical journal, receiving more than 3.2 million page views each year. The MJA has a journal impact factor (2016) of 3.68 and a 5-year impact factor of 4.10 (both recently revised upwards after errors in its calculation were identified), and received a record 10 610 citations during 2016, ranking us among the top 20 general medical journals in the world.

Just as importantly, articles published in the MJA attract broad social media and press interest. Authors who publish in the MJA thereby help shape public policy and medical practice across Australia and beyond. For example, our Perspective articles by leaders in health survey the broad medico-political landscape, and we are not afraid to publish evidence-based commentaries on controversial subjects that promote public debate. Moreover, our audience is global; more than one-third of our readers are located outside Australia: throughout the Asia–Pacific region and in North America, Europe, and the United Kingdom.

Improving our Journal

After refining the design of the print journal in 2016, earlier this year we comprehensively overhauled the design and organisation of our website (mja.com.au), making it more attractive for readers and easier to navigate, whether on a desktop monitor or a mobile device. Changes that are not so apparent will enhance the discoverability of our research reports and other articles in PubMed, Google Docs, and other search engines, an important service for our authors and readers. In 2018, further features will be added to our website, enabling readers to access and organise articles on topics or themes aligned with their research or clinical interests, for example.

We continue to publish high quality, evidence-based research and commentary, our emphasis on excellence underpinning all that we do. While readers must now register to access articles on mja.com.au, our original research articles and all content related to Indigenous health are freely accessible from the day they are published. Our policy of fee-free open access to these article types is unique in the world of top tier general medical journals, but we regard it a vital service for our authors, the broader medical research community, and clinicians.

Our editors have strived during 2017 to expedite manuscript decisions and processing, substantially reducing the average time for initial decisions from 19 to 5 days. Between July 2016 and June 2017 we published 40 full original research articles, as well as 32 reviews (including systematic reviews and meta-analyses) (Box).

We remain focused on publishing world class research, but are also deeply committed to publishing current content that educates and improves decision making by clinicians at the point of care. We receive and are publishing increasing numbers of guidelines and guideline summaries, and actively encourage their submission. Further, we have launched MJA online learning modules (RACGP Accredited Category 1) based on our guideline summaries (hosted on www.doctorportal.com).

Our engagement with doctors at all stages of their careers

The MJA is a leading voice for doctors’ health in Australia. We were involved in planning the national forum on reducing the risk of suicide in the medical profession that was held in September 2017. As part of our commitment, we made the 22 items published in the MJA or MJA InSight during 2017 that raised awareness of and advocated improving doctors’ health freely available to participants. Helping improve the health and lives of Australian doctors is a critical mission for the MJA, and we are proud to support and publish any initiatives that promote this outcome. We will continue to discuss doctors’ health in 2018.

We have increased our engagement with the Australian Medical Student Journal (www.amsj.org). We are keen to develop the editorial and research capabilities of the talented and committed medical students who produce this impressive journal, and in October our Senior Deputy Medical Editor led a professional development session for student editors in the offices of the MJA.

Clinical research is a primary focus of the MJA

As they did last year,1 the editors have selected the top ten research articles published during 2017. The choice was difficult, given the broad range of outstanding articles in our Journal over the past 12 months. Infectious diseases medicine was prominent on our list, reflecting its increasing importance in a world in which antibiotics may be losing their clout: antimicrobial resistance is rising as the result of their being overprescribed for both humans and animals. Amanda McCullough and her colleagues analysed data from the Bettering the Evaluation and Care of Health (BEACH) study to assess the prescribing of antibiotics for people with acute respiratory infections in Australian general practice; they found that antibiotics were prescribed for new acute respiratory infections during 2010–2015 at four to nine times the rates recommended by Therapeutic Guidelines.2 Curbing antibiotic overprescribing must remain a priority.

Alternatives to antibiotics are being explored, such as the increasing interest in stool transplants for treating Clostridium difficile-associated diarrhoea. In their systematic review of randomised controlled trials, Paul Moayyedi and colleagues concluded that there was moderate quality evidence that faecal microbial transplantation is significantly more effective than vancomycin or placebo for treating affected patients.3 Vaccines save lives, and one that protects against invasive disease caused by type B meningococcal infections has been available in Australia since 2014, but it is not (yet) funded by the National Immunisation Program. In their national epidemiological analysis of notified cases of meningococcal disease, Brett Archer and his co-authors found that the incidence of invasive disease caused by serogroup B meningococci during 2006–2015 was highest among infants under 12 months of age (11.1 cases per 100 000 person-years), and that the all-age incidence was almost four times higher among Indigenous than non-Indigenous Australians, particularly among Indigenous children.4 It is time to make the vaccine freely available to the vulnerable groups identified by this analysis.

The MJA welcomes high quality randomised controlled trials. An innovative example was the cluster randomised trial reported by Erica Tong and colleagues in which they compared error rates in medication management plans for general medical inpatients written by pharmacists with standard medical discharge summaries by medical officers. During a 4-month period, 265 of 431 standard medical discharge summaries (62%) included at least one medication error, compared with 60 of 401 discharge summaries completed by pharmacists (15%).5 Reducing medication error rates is evidently another high priority area for improving health care.

Although mortality rates have improved, heart disease is still a major killer in Australia. Accelerated diagnostic protocols (ADPs) are now recommended for managing chest pain suggestive of acute coronary syndromes.6 William Parsonage and colleagues evaluated the feasibility of one ADP in 16 Queensland public hospitals, and found that the mean total hospital length of stay fell from 57.7 hours to 47.3 hours after the ADP was introduced, that inpatient admission rates were reduced from 68.3% to 54.9%, and that mean emergency department length of stay declined from 292 to 256 minutes, all statistically significant results.7 However, the assessment of people presenting to emergency departments with a potential acute coronary syndrome is inefficient, given that most patients do not have a serious underlying pathology. Louise Cullen and co-authors examined the safety and efficacy of the Improved Assessment of Chest pain Trial (IMPACT) protocol, an accelerated strategy for assessing chest pain in emergency departments, and reported that three-quarters of patients presenting to emergency departments with chest pain could be safely and rapidly discharged home without further objective testing.8

The MJA is interested in health care at both ends of life. We published the study by Georgina Chambers and colleagues on the cumulative success rates for women undergoing assisted reproductive technology in Australia and New Zealand, a prospective follow-up of 56 652 women based on the analysis of complete ovarian stimulation cycles; these results are now informing public policy.9 We also published novel information about the cause and manner of premature deaths of nursing home residents, a report in which Joseph Ibrahim and colleagues noted that the incidence of deaths among nursing home residents that resulted from injuries, violence and other external events increased during 2001–2012. Most incidents were unintentional and falls-related, while the largest proportions of deaths attributed to suicide (55 cases, 38%) or resident-to-resident assault (14 cases, 41%) were among people aged 85–94 years.10 We will be examining the aged care system more closely in 2018, as it is a matter of national importance for us all.

Organ donation transforms lives, and not just those of the recipients. DonateLife undertook an audit of all patients aged 28 days to 80 years who had died in the intensive care or emergency departments of 75 Australian hospitals, and retrospectively assessed the potential numbers of suitable “donation after circulatory death” organ donors. Of 8 780 patients included in the final analysis, 202 were actual donors, 318 were deemed to be potential ideal donors, and a further 435 were potential donors according to expanded suitability criteria. Assuming a consent rate of 60%, the potential donors could have increased the national organ donation rate from 16.1 to 21.3 per million population in 2014, but in most cases donation had not been discussed with their families.11 More can clearly be done to improve our relatively low national donation rates.

Finally, medical education is of key interest to MJA readers. The inequitable distribution of the medical workforce, particularly in rural and remote Australia, has garnered national attention, and solutions are urgently needed. Denise Playford and colleagues found that Rural Clinical School training in Western Australia significantly increased the likelihood that medical students who commenced medical studies intending to practise in the country later actually worked in rural areas, but did not affect the choices of those without such an intention.12

Looking to the future

We have several innovative international collaborations planned for 2018–2019. For example, we are very excited to be working with colleagues from other leading medical journals on a special issue concerned with the health of indigenous peoples around the world. We will examine common and divergent approaches to the complex problems of delivering quality health care to indigenous communities, with the additional aim of building a body of quality global research in this area. We will also be launching a local initiative on planetary health in the coming year.

The MJA wishes all our readers, authors and reviewers a very happy holiday season. We appreciate your submissions, letters, feedback, and authoritative input, without which Australia would not have an outstanding medical journal. This year we particularly thank our first-time authors and reviewers. We also thank our talented Expert Advisory Group (https://www.mja.com.au/journal/staff/mja-editorial-advisory-committee), which we have further expanded to better cover the breadth and depth of medicine in Australia.