From the curious case of Patient K to TOP GEAR and Bond

Celebrating a great year for the MJA with our 2018 holiday issue

Welcome to the traditional summer edition of the MJA! In place of all the ground-breaking research, expert reviews, meta-analyses, and penetrating perspectives we publish throughout the year, we present a fascinating potpourri of the amusing and interesting articles and commentaries we have received as entries for our annual Christmas competition, before reviewing the best research we published during 2018.

The 2018 MJA Christmas competition

You might have wondered how James Bond can maintain his coordination and performance with blood alcohol levels as high as four times the legal limit; while his enemies may have failed to kill him, alcohol should have done the job. Perhaps it almost did: read all about it in this issue!1 Ellis and her colleagues remind us that our surgeons emulate Bond with their leanings to fast, expensive cars, whereas non-surgeons, in contrast, appear capable of at least some restraint in this regard2 (we unreservedly declare no conflict of interest: our Editorial judging team included no surgeons). Teo and Manivel’s perspective on societal trends in balancing the financial burdens and clinical care of private emergency department patients, on the other hand, is eye-opening.3 Bauman and colleagues delve into the ecology of the Mamil (middle-aged man in Lycra), finding, disappointingly, that their increased prevalence has not raised the overall physical activity levels of Australian adults.4 Clinicians could perhaps encourage regular cycling to work by swapping our trademark white coats for Lycra bodysuits! Maybe even Santa will take up cycling in the New Year now that his metabolic syndrome has been diagnosed.5 We should be optimistic, though: Cairns and colleagues remind us that we have moved from a time when we were thankful that our children survived Christmas to a world in which the risk that candles pose to carol singers is mitigated by waving electronic glow sticks instead.6 And you should no longer feel forlorn glimpsing 10-year-old Suzy on her tablet computer, showcasing the efficiency of digital advances for resolving logistic challenges ranging from Santa and his elves’ massive enterprise to simplifying the impossible task of choosing the right presents for your nearest and dearest.7

As we have come to expect, we had a strong field of contenders for this year’s prizes. We receive more submissions than we can accept, but thank all the contributors for their outstanding efforts. In particular, we congratulate this year’s winners: Nick Wilson and colleagues (New Zealand/United Kingdom) and Adrian Bauman and his Sydney co-authors could not be separated and share first place, narrowly edging out Melbourne playwright and retired GP Ron Elisha. Your hampers should reach you in good time for Christmas!

2018 in review: the top ten research articles

We are pleased to report that 2018 has been an excellent year for the MJA. We have published outstanding research, reviews, guidelines, and perspectives (Box), and our submissions, readership, and download numbers continue to grow. We remain committed to excellence and the translation of research findings into better clinical practice. Our Editorial team have again selected the top ten research articles of the past 12 months, each of which will be considered by the external MJA Expert Advisory Group for the annual $10 000 MJA, MDA National Prize for Excellence in Medical Research. The findings of the 2017 winners, who undertook a randomised controlled trial of an intervention for reducing medication errors in hospital discharge summaries,8 have already begun to change practice in the Monash Health system in Victoria.

The top ten research reports of 2018 include a randomised controlled evaluation of a peer-mentoring program for new medical interns at the Royal Perth Hospital. Fifty-three junior doctors (67%) elected to participate and were randomly allocated to receiving matched mentors one or two years their senior, or to receiving no mentor. Twelve months into the intervention, participants with mentors reported high satisfaction with the program and a positive impact on their stress levels, morale, sense of support, job satisfaction, and psychosocial wellbeing.9 It is gratifying to see randomised trial methodology applied to answering questions such as this, and we encourage others to use comparable approaches when investigating similar topics.

Cardiovascular disease research has been prominent in the Journal during 2018. Despite broader awareness of protocols for treating patients with ST-elevation myocardial infarction (STEMI), an important analysis of CONCORDANCE data found that revascularisation rates for women with STEMI were lower than for men, and that women were less frequently referred for cardiac rehabilitation or prescribed preventive medications at discharge, despite the fact that the mean GRACE risk score was higher for female than male patients. Rates of major adverse cardiovascular events and mortality during hospital admission were similar for men and women, but at 6 months were significantly higher for women.10 These data suggest that clinicians need to identify and remove potential barriers to guideline-recommended treatments for women with STEMI.

Another important study focused on the high rates of early re-admission and death after hospitalisation for heart failure. A cohort study of patients treated in six referral hospitals across five Australian states found that significant differences in 30- and 90-day re-admission rates were largely explained by differences in post-discharge management. Nurse-led disease management programs, together with early clinical review (7 days after discharge) or an exercise program, were particularly effective in reducing 90-day re-admission rates, but not mortality.11 These results suggest that outcomes for patients could be improved by adopting a uniform national policy for assisting patients with heart failure after their release from hospital.

Rheumatic heart disease has not completely disappeared from our region. Davis and her colleagues used echocardiography to screen 1365 school students aged 5–20 years in Timor-Leste, and identified 25 definite and 23 borderline cases of rheumatic heart disease, none of which had previously been diagnosed. The authors estimated the prevalence of definite rheumatic heart disease as 18.3 cases per 1000 population (95% CI, 12.3–27.0 per 1000), comparable with the highest rates documented anywhere in the world; it was more than three times as prevalent among girls as boys.12 These findings will be important for informing efforts to improve cardiovascular health in our region.

Australia has one of the highest anterior cruciate ligament (ACL) reconstruction rates in the world. Zbrojkiewicz and his co-authors analysed data from the National Hospital Morbidity Database to determine whether the demographic features of people undergoing reconstructions had changed during 2000–2015. Nearly 200 000 reconstructions had been undertaken (estimated annual direct costs, 2015: $134 million), and the annual incidence had risen across this period by 43% (from 54.0 to 77.4 per 100 000 population); that of revision surgery grew even more dramatically (by 127%). Particularly alarming was that the incidence of ACL reconstructions had grown most rapidly among 5–14-year-old children.13 Establishing a national injury prevention program and a national cruciate registry would be appropriate responses to these important findings.

Obstetric medicine featured prominently in the MJA during 2018. A retrospective cohort analysis of electronic maternity data identified a significant rise during 1990–2014 in the proportions of pregnant nulliparous women in Sydney who were overweight or obese, from 17.5% to 23.7%. This rise was associated with increases in the proportions of adverse maternal and neonatal outcomes attributable to being overweight, particularly gestational diabetes, fetal macrosomia, and pre-eclampsia.14 These findings have major clinical and public health implications, and a long term national response is urgently needed to ensure the health of future Australians.

In their meta-analysis of 20 investigations of cognitive performance during pregnancy, encompassing 709 pregnant and 521 non-pregnant women, Davies and colleagues found that general cognitive functioning (P = 0.014), memory (P = 0.017), and executive functioning (P = 0.036) were poorer in women during the third trimester of pregnancy than in control women.15 The authors acknowledged that the performance of pregnant women remained within the normal range, but their findings do appear to confirm that the popular idea of “baby brain” is not entirely aberrant!

Oncology and palliative care are research areas of great importance to Australians. A prospective population cohort study examined surveillance participation and outcomes for the 272 people who were diagnosed with hepatocellular carcinoma at tertiary hospitals in Melbourne during 2012–13. Surveillance was defined as 6-monthly ultrasound screening for patients with risk factors listed by international guidelines, including cirrhosis of any cause. The authors found a clear association between surveillance participation and reduced mortality (adjusted hazard ratio, 0.60; 95% CI, 0.38–0.93) and smaller tumour size.16 The surveillance participation rate, however, was only 40%, although 89% of patients qualified for surveillance. Participation should be increased by doctors counselling patients, and perhaps also by establishing a national screening program.

A large retrospective analysis of data from the Prostate Cancer Outcomes Registry Victoria similarly found that only 433 of 2134 men diagnosed with low risk prostate cancer during 2008–2014 (26.5%) adhered to the minimum standard for active surveillance, defined as at least one repeat biopsy and at least three prostate-specific antigen (PSA) tests in the 2 years after diagnosis. Many men may consequently be missing opportunities for appropriate treatment.17

An analysis of Victorian Cancer Registry data for the period 1985–2015 found that the incidence of invasive melanoma had declined among Victorians under 55 years of age (annual change, –1.7%; 95% CI, –2.5% to –0.9%), but was still increasing for those aged 55 or more (1.6%; 95% CI, 1.0–2.2%), although more slowly than before the mid-1990s.18 Melanoma is still a significant health problem, and prevention and early detection strategies should recognise sex- and age-related differences in presentation.

We thank the authors of these excellent articles and everyone who has published a paper with the MJA during 2018 — in itself a considerable achievement, given the quality of submissions we receive and the high bar set by the Journal.

Journal metrics and impact factor

Authors need to know whether their article is having an impact: being read and discussed, influencing policy, changing mindsets or practice, being cited, influencing future research directions, and, indeed, changing our world. At the MJA, we are committed to providing feedback to authors on the impact of their articles, and we are working on approaches for facilitating this process. Under the new NHMRC Investigator Grant scheme (previously: the Fellowship scheme), it will be even more important to measure and understand article impact, and the MJA plans to provide statements to authors in the near future that they can include in their applications. With respect to the most familiar metric of impact, I am pleased to report that the MJA this year achieved its highest ever impact factor (Box), and I am confident that it will rise further in coming years.

Our new partnership with Wiley, and Open Access

In 2019, the MJA will have a new publishing partner in Wiley. We will continue to provide free access on mja.com.au for all research articles, as we live by the principle that making research freely available maximises the opportunity for influencing practice and policy. Also as a matter of principle, we provide free access to all articles on Indigenous health as part of our contribution to closing the health gap between Indigenous and non-Indigenous Australians.

Together with Wiley, we will for the first time offer, at no cost to authors, a “green open access” model for all article types. In this model, authors may immediately archive the submitted version of their publication in an online repository with no embargo; after an embargo period (12 months), they will then be free to archive the accepted version on websites and in online repositories. As some overseas funders require that articles based on research they have supported be published under a “gold open access” arrangement (with a licensing agreement that permits immediate free downloading and sharing), we will also make this option available for a standard fee.

Further details on Open Access in the MJA will be published in the new year, but the important point for Australian researchers is that publishing in the MJA, a high impact journal, will still be free, and research articles will still be available in full online, under our standard licensing agreement, at no cost.

MJA: a general medical journal serving all specialties

The MJA is not exclusively a primary general practice journal. We are certainly proud to strongly support primary care, and we offer numerous important and useful articles aimed at specialist GPs. However, like other leading general medical journals, we cover a wide range of specialty interests from across the entire landscape of medicine. We publish guidelines from specialist societies that are hugely popular, and widely read and cited. We welcome reports on clinical trials and are now committed to fast-tracking their publication, including negative results from well designed investigations of important questions. We publish summaries of selected major research study protocols (eg, larger clinical trials and NHMRC-funded cohort studies) in print and the full protocols online to help guide future research. Our special Blue Section series continue to attract attention, including Clinical Skills, Research Methods, and Medical Education. New series have been commissioned for 2019, and we welcome any ideas and proposals about what would interest and help you in practice. In our Letters section, we encourage active correspondence about our research articles, and we regard this exchange as another step in the peer review process and a means for increasing research impact. Our Perspective articles provide a forum for airing evidence-based opinions, and we welcome spontaneous contributions, especially if they contribute to an existing debate or draw attention to a topic or question that our readers should know about.

Our Expert Advisory Group and peer reviewers

The MJA Expert Advisory Group (EAG) comprises outstanding researchers and clinicians from Australia and overseas (www.mja.com.au/journal/staff/mja-editorial-advisory-committee). Meeting twice a year, we thank the EAG for their advice, input, and feedback as we continue our journey to being a truly international general medical journal.

We also express our special thanks to our peer reviewers. Expert peer review is a cornerstone of excellence in medical publishing, and at the MJA every research article undergoes double blind peer review, including statistical review. The MJA Editorial team also independently appraise all articles we receive, supported by our in-house study design, biostatistics, and epidemiologic expertise. But without the support of our peer reviewers, there would be no MJA, and we thank each and every one who has reviewed for us in 2018 (pages 471-473).

Season’s greetings

The Editorial team at the MJA wish you and your families a happy, healthy and glorious summer holiday. We look forward to celebrating with all Australians the great tradition of a long and warm summer break, family get-togethers and barbecues, and holidays. We salute the dedication, excellence, and professionalism of all the health professionals who are working over this period, and hope that you too soon find time for a proper break. Please recharge and renew; your patients and your community need and value you. We look forward to welcoming all our readers and authors back in January!