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    Ambulance ramping and patients with cardiac‐type symptoms: understanding the unloading queue

    Gao Jing Ong and John D Horowitz
    Med J Aust 2022; 217 (5): . || doi: 10.5694/mja2.51677
    Published online: 5 September 2022

    Prioritisation for unloading, once obvious cardiac emergencies have been excluded, disadvantages women and older people

    About 10–20% of people transported by emergency ambulance to hospital have (presumptively cardiac) chest pain.1 Our management of these patients is inevitably geared to the possibility of evolving myocardial infarction, in which case any delay in initiating definitive treatment to restore coronary perfusion will increase the short and long term risks of death.2 The three major sources of delay after the ambulance collects the patient are the time taken to deliver the patient to a suitable hospital, the waiting period outside the emergency department before unloading the patient, and within‐hospital barriers to treatment initiation, such as delays in definite diagnosis and the availability of suitably trained staff for delivering definitive treatment. For most purposes, it is best to consider barriers to treatment as a “series resistance model”: what ultimately matters is to ensure that treatment is delivered as expeditiously as possible.


    • 1 Central Adelaide Local Health Network, Adelaide, SA
    • 2 Basil Hetzel Institute for Translational Health Research, Adelaide, SA
    • 3 The University of Adelaide, Adelaide, SA


    Competing interests:

    No relevant disclosures.

    • 1. Burman RA, Zakaraissen E, Hunskaar S. Acute chest pain: a prospective population‐based study of contacts to Norwegian emergency medical communications centres. BMC Emerg Med 2011; 11: 9.
    • 2. Scholz KH, Maier SKG, Maier LS, et al. Impact of treatment delay on mortality in ST‐segment elevation myocardial infarction (STEMI) patients presenting with and without haemodynamic instability: results from the German prospective, multicentre FITT‐STEMI trial. Eur Heart J 2018; 39: 1065‐1074.
    • 3. Woodward T, Hocking J, James L, Johnson D. Impact of an emergency department‐run clinical decision unit on access block, ambulance ramping and National Emergency Access Target. Emerg Med Australas 2019; 31: 200‐204.
    • 4. Schull MJ, Morrison LJ, Vermeulen M, Redelmeier DA. Emergency department overcrowding and ambulance transport delays for patients with chest pain. CMAJ 2003; 168: 277‐283.
    • 5. Dawson LP, Andrew E, Stephenson M, et al. The influence of ambulance offload time on 30‐day risks of death and re‐presentation for patients with chest pain. Med J Aust 2022; 217: 253‐259.
    • 6. Pedersen GJ, Stengaard C, Friesgaard K, et al. Chest pain in the ambulance: prevalence, causes and outcome: a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2019; 27: 84.
    • 7. Elbadawi A, Elgendi IY, Najvi SY, et al. Temporal trends and outcomes of hospitalisations with Prinzmetal angina: perspectives from a national database. Am J Med 2019; 132: 1053‐1061.
    • 8. Ghadri JR, Wittstein IS, Prasad A, et al. Expert consensus document on takotsubo syndrome (part 1): clinical characteristics, diagnostic criteria, and pathophysiology. Eur Heart J 2018; 39: 2032‐2046.

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      Clearing elective surgery waiting lists after the COVID‐19 pandemic cannot be allowed to compromise emergency surgery care

      Robert J Aitken and David AK Watters
      Med J Aust 2022; 217 (5): . || doi: 10.5694/mja2.51672
      Published online: 5 September 2022

      Many patients with gallstone pancreatitis were not receiving timely, surgical care even before the pandemic

      Elective surgery waiting lists have long been a sensitive political issue.1 Reducing the increased backlog and waiting times caused by coronavirus disease 2019 (COVID‐19) pandemic‐related restrictions on elective surgery will be a major health priority during the next three to five years. Delaying emergency surgery is one approach used to prioritise elective surgery, but focusing on elective surgery rates may result in delayed theatre access for emergency operations,2,3 compromising emergency surgery outcomes and prolonging hospital stays and consequently increasing costs.

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      • 1 Sir Charles Gairdner Hospital, Perth, WA
      • 2 Deakin University, Geelong, VIC
      • 3 Barwon Health, Geelong, VIC


      Correspondence: rjaitken@me.com
      Competing interests:

      No relevant disclosures.

      • 1. Curtis AJ, Russell COH, Stoelwinder JU, McNeil JJ. Waiting lists and elective surgery: ordering the queue. Med J Aust 2010; 192: 217‐220. https://www.mja.com.au/journal/2010/192/4/waiting‐lists‐and‐elective‐surgery‐ordering‐queue
      • 2. NSW Agency for Clinical Innovation. NSW emergency surgery guidelines and principles for improvement (GL2021_007). 18 May 2021. https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2021_007.pdf (viewed Apr 2022).
      • 3. Deane SA, MacLellan DG, Meredith GL, Cregan PC; Surgical Services Taskforce Emergency Surgery Sub‐group. Making sense of emergency surgery in New South Wales: a position statement. ANZ J Surg 2010; 80: 139‐144.
      • 4. Blundell JD, Gandy RC, Close J, Harvey L. Cholecystectomy for people aged 50 years or more with mild gallstone pancreatitis: predictors and outcomes of index and interval procedures. Med J Aust 2022; 217: 246‐252.
      • 5. De Mestral C, Nathens AB. Cholecystectomy in mild gallstone pancreatitis: don’t defer. Lancet 2015; 386: 1218‐1219.
      • 6. Le Manach Y, Collins G, Bhandari M, et al. Outcomes after hip fracture surgery compared with elective total hip replacement. JAMA 2015; 314: 1159‐1166.
      • 7. Mullen MG, Michaels AD, Mehaffey JH, et al. Risk associated with complications and mortality after urgent surgery vs elective and emergency surgery implications for defining “quality” and reporting outcomes for urgent surgery. JAMA Surg 2017; 152: 768‐774.
      • 8. Danford NC, Logue TC, Boddapati V, et al. Debate update: surgery after 48 hours of admission for geriatric hip fracture patients is associated with increase in mortality and complication rate: a study of 27 058 patients using the National Trauma Data Bank. J Orthop Trauma 2021; 35: 535‐541.
      • 9. Australian and New Zealand Hip Fracture Registry. Annual report 2021 (figure 23). Sept 2021. https://anzhfr.org/wp‐content/uploads/sites/1164/2021/12/ANZHFR_eReport2021‐FA.pdf (viewed May 2022).
      • 10. Aitken RJ, Griffiths B, van Acker J, et al; ANZELA‐QI Working Party. Two‐year outcomes from the Australian and New Zealand Emergency Laparotomy Audit – Quality Improvement pilot. ANZ J Surg 2021; 91: 2575‐2582.
      • 11. NELA Project Team. Seventh patient report of the National Emergency Laparotomy Audit. Nov 2021. https://www.nela.org.uk/Seventh‐Patient‐Report#pt (viewed Apr 2022).
      • 12. Drysdale HRE, Ooi S, Geelong Surgical COVID‐19 Response Team, Nagra S, et al. Clinical activity and outcomes during Geelong’s general surgery response to the coronavirus disease 2019 pandemic. ANZ J Surg 2020; 90: 1573‐1579.
      • 13. Boyd‐Carson H, Doleman B, Cromwell D, et al; National Emergency Laparotomy Audit Collaboration. Delay in source control in perforated peptic ulcer leads to 6% increased risk of death per hour: a nationwide cohort study. World J Surg 2020; 44: 869‐875.
      • 14. Australian Government. Maximising the value of Australia’s clinical quality outcomes data. a national strategy for clinical quality registry and virtual registries 2020–2030. Updated 14 Dec 2021. https://www1.health.gov.au/internet/main/publishing.nsf/Content/national_clinical_quality_registry_and_virtual_registry_strategy_2020‐2030 (viewed Apr 2022).

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        Advertising by orthopaedic surgeons: the tension between professionalism and commercialism

        Peter FM Choong
        Med J Aust 2022; 217 (5): . || doi: 10.5694/mja2.51676
        Published online: 5 September 2022

        Translating guidelines into practice is required to maintain the balance between practitioner autonomy and accountability

        Medical professionals assure us that they will only provide care that limits harm (non‐maleficence) and promotes the best outcomes (beneficence) for patients. The basis of this social contract is the expectation of integrity, morality, and altruism in their business practices, making doctors trustworthy sources of good health care. A doctor’s first duty is to their patient, a dictum as relevant today as it was for Hippocrates. In our complex society, it is more important than ever that doctors are trusted by their patients. In return, doctors enjoy autonomy of practice, status in society, and self‐regulation.


        • The University of Melbourne, Melbourne, VIC


        Correspondence: pchoong@unimelb.edu.au
        Acknowledgements: 

        I am supported by a National Health and Medical Research Council Practitioner Fellowship.

        Competing interests:

        I received consultancy fees for advisory and design work from Johnson & Johnson, and from Stryker.

        • 1. Ryan HY, Sun GY, Monuja M, et al. Adherence by orthopaedic surgeons to AHPRA and Australian Orthopaedic Association advertising guidelines. Med J Aust 2022; 217: 240‐245.
        • 2. Hesse BW, Greenberg AJ, Rutten LJF. The role of Internet resources in clinical oncology: promises and challenges. Nat Rev Clin Oncol 2016; 13: 767‐776.
        • 3. Schneller ES, Wilson NA. Professionalism in 21st century professional practice: autonomy and accountability in orthopaedic surgery. Clin Orthop Relat Res 2009; 467: 2561‐2569.
        • 4. Jones JW, McCullough LB. Is medical advertising always unethical, or does it just seem to be? J Vasc Surg 2015; 61: 1635‐1636.
        • 5. Davaris MT, Dowsey MM, Bunzli S, Choong PF. Arthroplasty information on the internet: quality or quantity? Bone Jt Open 2020; 1: 64‐73.
        • 6. Australian Health Practitioner Regulation Agency. AHPRA and national boards annual report 2020/21. www.ahpra.gov.au/annualreport (viewed June 2022).
        • 7. Australian Health Practitioner Regulation Agency. Guidelines for advertising a regulated health service. Reviewed 9 Feb 2021. https://www.ahpra.gov.au/Resources/Advertising‐hub/Advertising‐guidelines‐and‐other‐guidance/Advertising‐guidelines.aspx (viewed June 2022).
        • 8. Holden A. Soon Australian doctors will be allowed to advertise with patient testimonials: but beware the hype. The Conversation (Australia) [online], 25 May 2022. https://theconversation.com/soon‐australian‐doctors‐will‐be‐allowed‐to‐advertise‐with‐patient‐testimonials‐but‐beware‐the‐hype‐183126 (viewed June 2022).
        • 9. Fischer F, Lange K, Klose K, et al. Barriers and strategies in guideline implementation: a scoping review. Healthcare (Basel) 2016; 4: 36.

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          Is D‐dimer the new test for venom‐induced consumption coagulopathy after snakebite?

          Mark Little
          Med J Aust 2022; 217 (4): . || doi: 10.5694/mja2.51663
          Published online: 15 August 2022

          Despite its potential value, a number of questions require answers before its role in clinical practice becomes clear

          For many clinicians working in rural Australia, people bitten by snakes can present significant diagnostic and logistical challenges. The current advice is that these patients be managed in a hospital with a laboratory, antivenom, and clinicians who can manage the complications of both the envenoming (such as neurotoxicity) and the antivenom (anaphylaxis).1 As many rural hospitals have limited or no immediate access to laboratories, patients (many of whom are not envenomed) must be transported hundreds of kilometres, often after hours. As envenomed patients do better if antivenom is administered early, delaying its provision can increase the risks of complications. Consequently, simple and accurate bedside investigations for diagnosing or excluding envenoming are urgently required, both in Australia and overseas.2


          • 1 Cairns Hospital, Cairns, QLD, Australia
          • 2 NSW Poisons Information Centre, Children's Hospital at Westmead, Sydney, NSW, Australia


          Competing interests:

          I am a toxicologist employed at the NSW Poisons Information Centre and give advice to doctors managing snakebites. I am the editor of two textbooks, Toxicology handbook, third edition (Murray L, Little M, Pascu O, Hoggett K, eds; Sydney: Elsevier, 2015) and Adult emergency medicine, fifth edition (Cameron P, Little M, Mitra B, Deasy C, eds; Edinburg: Elsevier, 2020) in which the management of snakebite is discussed. I assisted CSL in reviewing the book A clinician’s guide to Australian venomous bites and stings (White J, ed; Melbourne: CSL, 2013).

          • 1. Isbister GK, Brown SB, Page CB, et al. Snakebite in Australia: a practical approach to diagnosis and treatment. Med J Aust 2013; 199: 763‐768. https://www.mja.com.au/journal/2013/199/11/snakebite‐australia‐practical‐approach‐diagnosis‐and‐treatment
          • 2. Hamza M, Knudsen C, Gnanathasan CA, et al. Clinical management of snakebite envenoming: future perspectives. Toxicon X 2021; 11: 100079.
          • 3. Isbister GK, Noutsos T, Jenkins S, et al. D‐dimer testing for early detection of venom‐induced consumption coagulopathy after snakebite in Australia (ASP‐29). Med J Aust 2022; 217: 203‐207.
          • 4. Isbister GK, Duffill SB, Brown SB et al; ASP Investigators. Failure of antivenom to improve recovery in Australian snakebite coagulopathy. QJM 2009; 8: 563‐568.
          • 5. Therapeutic Guidelines. Snake bite. In: Toxicology and Toxinology [published 2022]. https://tgldcdp.tg.org.au/guideLine?guidelinePage=Toxicology+and+Toxinology&frompage=etgcomplete (viewed June 2022).
          • 6. Cubitt M, Armstrong J, McCoubrie D, et al. Point of care testing in snakebite: an envenomed case with false negative coagulation studies. Emerg Med Australasia 2013; 25: 372‐373.
          • 7. World Health Organization. Snakebite envenoming. 17 May 2021. https://www.who.int/news‐room/fact‐sheets/detail/snakebite‐envenoming (viewed May 2022).
          • 8. Hadley GP, McGarr P, Mars M. The role of thromboelastography in the management of children with snake‐bite in southern Africa. Trans R Soc Trop Med Hyg 1999; 93: 177‐179.
          • 9. Dang XT, NguyenTX, Nguyen TTH, et al. Coagulation after viper snakebite in Vietnam and relationship with time of admission. J Multidiscip Healthc 2021; 14: 1259‐1265.
          • 10. Tacon CL, Munas A, Little M. Rotational thromboelastometry in taipan envenomation. Am J Trop Med Hyg 2022; 106: 746‐749.

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            Vaccine safety: what systems are required to ensure public confidence in vaccines?

            Allen C Cheng and Jim P Buttery
            Med J Aust 2022; 217 (4): . || doi: 10.5694/mja2.51662
            Published online: 15 August 2022

            No single surveillance system is perfect, but integrating data from multiple sources can provide comprehensive and reliable signal detection

            Although phase 3 pre‐licensing vaccine studies typically include tens of thousands of participants, they generally cannot detect rare adverse events following immunisation (AEFI). Further, participants in clinical trials are generally highly selected, and safety profiles may be different when programs are applied to broader populations. Robust systems for detecting AEFI (post‐marketing surveillance) are therefore essential when large scale vaccination programs are implemented.


            • 1 Monash University, Melbourne, VIC
            • 2 Surveillance of Adverse Events Following Vaccination In the Community (SAEFVIC), Murdoch Children’s Research Institute, Melbourne, VIC


            Correspondence: allen.cheng@monash.edu
            Competing interests:

            No relevant disclosures.

            • 1. Gold MS, Effler P, Kelly H, et al. Febrile convulsions after 2010 seasonal trivalent influenza vaccine: implications for vaccine safety surveillance in Australia. Med J Aust 2010; 193: 492‐493. https://www.mja.com.au/journal/2010/193/9/febrile‐convulsions‐after‐2010‐seasonal‐trivalent‐influenza‐vaccine‐implications
            • 2. Martin JH, Lucas C. Reporting adverse drug events to the Therapeutic Goods Administration. Aust Prescr 2021; 44: 2‐3.
            • 3. Clothier HJ, Lawrie J, Russell MA, et al. Early signal detection of adverse events following influenza vaccination using proportional reporting ratio, Victoria, Australia. PLoS One 2019; 14: e0224702.
            • 4. Clothier HJ, Crawford NW, Russell M, et al. Evaluation of “SAEFVIC”, a pharmacovigilance surveillance scheme for the spontaneous reporting of adverse events following immunisation in Victoria, Australia. Drug Saf 2017; 40: 483‐495.
            • 5. World Health Organization. Causality assessment of an adverse event following immunization (AEFI): user manual for the revised WHO classification. 2nd edition, 2019 update. https://www.who.int/publications/i/item/9789241516990 (viewed June 2022).
            • 6. Hocking J, Chunilal SD, Chen VM, et al. The first known case of vaccine‐induced thrombotic thrombocytopenia in Australia. Med J Aust 2021; 215: 19‐20.e1. https://www.mja.com.au/journal/2021/215/1/first‐known‐case‐vaccine‐induced‐thrombotic‐thrombocytopenia‐australia
            • 7. Osowicki J, Morgan H, Harris A, et al. Guillain–Barre syndrome in an Australian state using both mRNA and adenovirus‐vector SARS‐CoV‐2 vaccines. Ann Neurol 2021; 90: 856‐858.
            • 8. Wong J, Sharma S, Yao JV, et al. COVID‐19 mRNA vaccine (Comirnaty)‐induced myocarditis. Med J Aust 2022; 216: 122‐123. https://www.mja.com.au/journal/2022/216/3/covid‐19‐mrna‐vaccine‐comirnaty‐induced‐myocarditis
            • 9. Cashman P, Macartney K, Khandaker G, et al. Participant‐centred active surveillance of adverse events following immunisation: a narrative review. Int Health 2017; 9: 164‐176.
            • 10. Deng L, Glover C, Dymock M, et al. The short term safety of COVID‐19 vaccines in Australia: AusVaxSafety active surveillance, February – August 2021. Med J Aust 2022; 217: 195‐202.
            • 11. Pillsbury AJ, Glover C, Jacoby P, et al. Active surveillance of 2017 seasonal influenza vaccine safety: an observational cohort study of individuals aged 6 months and older in Australia. BMJ Open 2018; 8: e023263.
            • 12. Phillips A, Carlson S, Danchin M, et al. From program suspension to the pandemic: a qualitative examination of Australia’s vaccine pharmacovigilance system over 10 years. Vaccine 2021; 39: 5968‐5981.
            • 13. King C, Leask J. The impact of a vaccine scare on parental views, trust and information needs: a qualitative study in Sydney, Australia. BMC Public Health 2017; 17: 106.
            • 14. Mesfin YM, Cheng AC, Enticott J, et al. Post‐vaccination healthcare attendance rate as a proxy measure for syndromic surveillance of adverse events following immunisation. Aust N Z J Public Health 2021; 45: 101‐107.
            • 15. Mesfin YM, Cheng A, Lawrie J, Buttery J. Use of routinely collected electronic healthcare data for postlicensure vaccine safety signal detection: a systematic review. BMJ Glob Health 2019; 4: e001065.
            • 16. Lai LY, Arshad F, Areia C, et al. Current approaches to vaccine safety using observational data: a rationale for the EUMAEUS (Evaluating Use of Methods for Adverse Events Under Surveillance‐for Vaccines) study design. Front Pharmacol 2022; 13: 837632.
            • 17. Crawford NW, Hodgson K, Gold M, et al; AEFI‐CAN network. Adverse events following HPV immunization in Australia: establishment of a clinical network. Hum Vaccin Immunother 2016; 12: 2662‐2665.

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              What causes multiple sclerosis? Getting closer to the answers

              Bruce V Taylor
              Med J Aust 2022; 217 (4): . || doi: 10.5694/mja2.51645
              Published online: 15 August 2022

              MS risk is becoming less of a mystery as we gain a better understanding of its causes

              Multiple sclerosis (MS) is a complex neuroinflammatory/neurodegenerative disease of the central nervous system. Recent work1,2 has significantly advanced our understanding of the aetiology of MS, emphasising the importance of infection with Epstein–Barr virus as a significant driver of MS risk. MS manifests clinically as neurological dysfunction affecting any area of the central nervous system, in particular the optic nerves, spinal cord, and brainstem. Most people with MS (90%) present with relapse onset MS where episodes of neurological dysfunction are followed by partial or full recovery but over time, disability almost invariably accumulates (secondary progressive MS).3 In contrast, 10% of people present with progression from disease onset, termed progressive onset MS.3 In the developed world, MS is one of the leading causes of neurological disability in young adults, and as the median age of onset in Australia is between 35 and 40 years,4 it affects people in their most productive years. Consequently, the economic and social costs to individuals and the wider community are high. In 2017, we estimated the cost of MS to Australia was $1.7 billion annually and increasing significantly each year.5 Currently, there is no cure for MS, but significant gains have been made in its treatment, particularly the use of highly effective disease‐modifying therapies and the development of comprehensive care through specialised MS clinics. However, no current treatment can stop or reverse the neurodegenerative component of the disease.3


              • Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia


              Correspondence: bruce.taylor@utas.edu.au
              Acknowledgements: 

              I receive National Health and Medical Research Council Leadership Fellow salary support.

              Competing interests:

              No relevant disclosures.

              • 1. Bjornevik K, Cortese M, Healy BC, et al. Longitudinal analysis reveals high prevalence of Epstein‐Barr virus associated with multiple sclerosis. Science 2022; 375: 296‐301.
              • 2. Wekerle H. Epstein‐Barr virus sparks brain autoimmunity in multiple sclerosis. Nature 2022; 603: 230‐232.
              • 3. Thompson AJ, Baranzini SE, Geurts J, et al. Multiple sclerosis. Lancet 2018; 391: 1622‐1636.
              • 4. Taylor BV, Lucas RM, Dear K, et al. Latitudinal variation in incidence and type of first central nervous system demyelinating events. Mult Scler 2010; 16: 398‐405.
              • 5. Ahmad H, Campbell JA, van der Mei I, et al. The increasing economic burden of multiple sclerosis by disability severity in Australia in 2017: results from updated and detailed data on types of costs. Mult Scler Relat Disord 2020; 44: 102247.
              • 6. Belbasis L, Bellou V, Evangelou E, et al. Environmental risk factors and multiple sclerosis: an umbrella review of systematic reviews and meta‐analyses. Lancet Neurol 2015; 14: 263‐273.
              • 7. Waubant E, Lucas R, Mowry E, et al. Environmental and genetic risk factors for MS: an integrated review. Ann Clin Transl Neurol 2019; 6: 1905‐1922.
              • 8. Rothman KJ, Greenland S. Causation and causal inference in epidemiology. Am J Public Health 2005; 95 Suppl 1: S144‐S150.
              • 9. Trojano M, Lucchese G, Graziano G, et al. Geographical variations in sex ratio trends over time in multiple sclerosis. PLoS One 2012; 7: e48078.
              • 10. Bove R, Chitnis T. The role of gender and sex hormones in determining the onset and outcome of multiple sclerosis. Mult Scler 2014; 20: 520‐526.
              • 11. O'Gorman C, Freeman S, Taylor BV, et al. Familial recurrence risks for multiple sclerosis in Australia. Neurol Neurosurg Psychiatry 2011; 82: 1351‐1354.
              • 12. International Multiple Sclerosis Genetics Consortium. Multiple sclerosis genomic map implicates peripheral immune cells and microglia in susceptibility. Science 2019; 365: eaav7188.
              • 13. Kurtzke JF. A reassessment of the distribution of multiple sclerosis. Acta Neurol Scand 1975; 51: 137‐157.
              • 14. Amezcua L, McCauley JL. Race and ethnicity on MS presentation and disease course. Mult Scler 2020; 26: 561‐567.
              • 15. Taylor BV, Pearson JF, Clarke G, et al. MS prevalence in New Zealand, an ethnically and latitudinally diverse country. Mult Scler 2010; 16: 1422‐1431.
              • 16. Simpson S, Jr, Wang W, Otahal P, et al. Latitude continues to be significantly associated with the prevalence of multiple sclerosis: an updated meta‐analysis. J Neurol Neurosurg Psychiatry 2019; 90: 1193‐1200.
              • 17. Lucas RM, Ponsonby AL, Dear K, et al. Sun exposure and vitamin D are independent risk factors for CNS demyelination. Neurology 2011; 76: 540‐548.
              • 18. van der Mei IA, Ponsonby AL, Blizzard L, Dwyer T. Regional variation in multiple sclerosis prevalence in Australia and its association with ambient ultraviolet radiation. Neuroepidemiology 2001; 20: 168‐174.
              • 19. Sabel CE, Pearson JF, Mason DF, et al. The latitude gradient for multiple sclerosis prevalence is established in the early life course. Brain 2021; 144: 2038‐2046.
              • 20. Kimlin MG, Lucas RM, Harrison SL, et al. The contributions of solar ultraviolet radiation exposure and other determinants to serum 25‐hydroxyvitamin D concentrations in Australian adults: the AusD Study. Am J Epidemiol 2014; 179: 864‐874.
              • 21. Campbell JA, Simpson S, Jr, Ahmad H, et al. Change in multiple sclerosis prevalence over time in Australia 2010‐2017 utilising disease‐modifying therapy prescription data. Mult Scler 2020; 26: 1315‐1328.
              • 22. Pakpoor J, Schmierer K, Cuzick J, et al. Estimated and projected burden of multiple sclerosis attributable to smoking and childhood and adolescent high body‐mass index: a comparative risk assessment. Int J Epidemiol 2021; 49: 2051‐2057.
              • 23. van der Mei I, Lucas RM, Taylor BV, et al. Population attributable fractions and joint effects of key risk factors for multiple sclerosis. Mult Scler 2016; 22: 461‐469.
              • 24. Simpson S, Jr, van der Mei I, Lucas RM, et al. Sun exposure across the life course significantly modulates early multiple sclerosis clinical course. Front Neurol 2018; 9: 16.
              • 25. Michaelsson K, Baron JA, Snellman G, et al. Plasma vitamin D and mortality in older men: a community‐based prospective cohort study. Am J Clin Nutr 2010; 92: 841‐848.
              • 26. Holick MF. Sunlight, UV radiation, vitamin D, and skin cancer: how much sunlight do we need? Adv Exp Med Biol 2020; 1268: 19‐36.
              • 27. Alfredsson L, Armstrong BK, Butterfield DA, et al. Insufficient sun exposure has become a real public health problem. Int J Environ Res Public Health 2020; 17: 5014.

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                Transforming health settings to address gender‐based violence in Australia

                Kelsey L Hegarty, Shawana Andrews and Laura Tarzia
                Med J Aust 2022; 217 (3): . || doi: 10.5694/mja2.51638
                Published online: 1 August 2022

                Summary

                • Gender‐based violence includes intimate partner violence, sexual violence and other harmful acts directed at people based on their gender. It is common in Australia and causes great ill health, especially for women victims/survivors, with Indigenous women particularly affected.
                • Health services are an opportune place for early intervention for victims/survivors of gender‐based violence as they attend frequently.
                • Interventions that are evidence‐based and respond to consensus from victim/survivor voices include universal education, screening in antenatal care, first line supportive care, and referral for advocacy and psychological interventions, including mother–child work.
                • Health care staff require training, protocols, scripts, referral pathways, understanding of cultural safety and antiracist practice in service delivery, and leadership support to undertake this sensitive work, including support, if needed, for their own experiences of gender‐based violence.
                • Using a trauma‐, violence‐ and gender‐informed approach across health systems, taking into account structural inequities, is essential to sustain the gender‐based violence work in health services.
                • Gender‐based violence experienced by Indigenous women is distinct and of urgent concern as rates rapidly increase. Inequities across the health system are pronounced for Indigenous women.

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                • 1 Safer Families Centre, University of Melbourne, Melbourne, VIC
                • 2 Centre for Family Violence Prevention, Royal Women’s Hospital, Melbourne, VIC
                • 3 Melbourne Poche Centre for Indigenous Health, University of Melbourne, Melbourne, VIC


                Correspondence: k.hegarty@unimelb.edu.au

                Open access

                Open access publishing facilitated by The University of Melbourne, as part of the Wiley ‐ The University of Melbourne agreement via the Council of Australian University Librarians.

                Acknowledgements: 

                The Safer Families Centre is funded by the National Health and Medical Research Council (NHMRC) grant No. 1116690. The NHMRC did not have any role in the planning, writing or publication of the work.

                Competing interests:

                No relevant disclosures.

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                  Stroke is more than a hemiparesis: the pre‐hospital detection of stroke

                  Else Charlotte Sandset and Maren Ranhoff Hov
                  Med J Aust 2022; 217 (3): . || doi: 10.5694/mja2.51654
                  Published online: 1 August 2022

                   

                  The first step to improving outcomes for women with stroke is to identify them


                  • 1 European Stroke Organisation, Basel, Switzerland
                  • 2 Oslo University Hospital, Oslo, Norway
                  • 3 Norwegian Air Ambulance Foundation, Bodo, Norway


                  Correspondence: else@sandset.net
                  Competing interests:

                  No relevant disclosures.

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                  • 2. Shajahan S, Sun L, Harris K, et al. Sex differences in the symptom presentation of stroke: A systematic review and meta‐analysis. Int J Stroke 2022; doi: https://doi.org/10.1177/17474930221090133 [online ahead of print].
                  • 3. Ali M, van Os HJA, van der Weerd N, et al. Sex differences in presentation of stroke: a systematic review and meta‐analysis. Stroke 2022; 53: 345‐354.
                  • 4. Bonkhoff AK, Schirmer MD, Bretzner M, et al; MRI‐GENIE and GISCOME Investigators and the International Stroke Genetics Consortium. Outcome after acute ischemic stroke is linked to sex‐specific lesion patterns. Nature Commun 2021; 12: 3289.
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                  • 6. Jones SP, Bray JE, Gibson JM, et al. Characteristics of patients who had a stroke not initially identified during emergency prehospital assessment: a systematic review. Emerg Med J 2021; 38: 387‐393.
                  • 7. Duvekot MHC, Venema E, Rozeman AD, et al; PRESTO investigators. Comparison of eight prehospital stroke scales to detect intracranial large‐vessel occlusion in suspected stroke (PRESTO): a prospective observational study. Lancet Neurol 2021; 20: 213‐221.
                  • 8. Bugge HF, Guterud M, Bache KCG, et al. Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) study protocol: a stepped wedge randomised trial of stroke screening using the National Institutes of Health Stroke Scale in the ambulance. Trials 2022; 23: 113.
                  • 9. Koka A, Suppan L, Cottet P, et al. Teaching the National Institutes of Health Stroke Scale to paramedics (e‐learning vs video): randomized controlled trial. J Med Internet Res 2020; 22: e18358.

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                    Striving for gender equity at the Medical Journal of Australia

                    Alisha Dorrigan, Elizabeth Zuccala and Nicholas J Talley
                    Med J Aust 2022; 217 (3): . || doi: 10.5694/mja2.51642
                    Published online: 1 August 2022

                    Diversity and equity are both imperative when it comes to publishing high quality literature that promotes better health outcomes

                    In 2019, the Medical Journal of Australia put out a call for articles and asked the question: “Women in medicine and medical leadership in Australia — is there gender equity?”

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                    • Medical Journal of Australia, Sydney, NSW


                    Correspondence: adorrigan@mja.com.au
                    Competing interests:

                    A complete list of Nick Talley’s disclosures is available at https://www.mja.com.au/journal/staff/editor‐chief‐professor‐nick‐talley.

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                    • 22. Heidari S, Babor T, De Castro P, et al. Sex and gender equity in research: rationale for the SAGER guidelines and recommended use. Res Integr Peer Rev 2016; 1: 2.

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                      Review of management priorities for invasive infections in people who inject drugs: highlighting the need for patient‐centred multidisciplinary care

                      Lucy O Attwood, Megan McKechnie, Olga Vujovic, Peter Higgs, Martyn Lloyd‐Jones, Joseph S Doyle and Andrew J Stewardson
                      Med J Aust 2022; 217 (2): . || doi: 10.5694/mja2.51623
                      Published online: 18 July 2022

                      Summary

                      • There has been a global increase in the burden of invasive infections in people who inject drugs (PWID).
                      • It is essential that patient‐centred multidisciplinary care is provided in the management of these infections to engage PWID in care and deliver evidence‐based management and preventive strategies.
                      • The multidisciplinary team should include infectious diseases, addictions medicine (inclusive of alcohol and other drug services), surgery, psychiatry, pain specialists, pharmacy, nursing staff, social work and peer support workers (where available) to help address the comorbid conditions that may have contributed to the patient’s presentation.
                      • PWID have a range of antimicrobial delivery options that can be tailored in a patient‐centred manner and thus are not limited to prolonged hospital admissions to receive intravenous antimicrobials for invasive infections. These options include discharge with outpatient parenteral antimicrobial therapy, long‐acting lipoglycopeptides (dalbavancin and oritavancin) and early oral antimicrobials.
                      • Open and respectful discussion with PWID including around harm reduction strategies may decrease the risk of repeat presentations with injecting‐related harms.

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                      • 1 Alfred Health, Melbourne, VIC
                      • 2 Monash University, Melbourne, VIC
                      • 3 Burnet Institute, Melbourne, VIC
                      • 4 La Trobe University, Melbourne, VIC


                      Correspondence: lucy.attwood@monash.edu

                      Open access

                      Open access publishing facilitated by Monash University, as part of the Wiley – Monash University agreement via the Council of Australian University Librarians.

                      Acknowledgements: 

                      The authors acknowledge the work of Thuy Bui and Kelly Cairns for their assistance reviewing the pharmacology in this article. The Burnet Institute acknowledges support from the Victorian Government Operational Infrastructure Fund. Lucy Attwood receives postgraduate support from the Australian National Health and Medical Research Council (NHMRC). Joseph Doyle and Andrew Stewardson receive Fellowship support from the NHMRC.

                      Competing interests:

                      Peter Higgs has received investigator‐driven research funding from Gilead Sciences and AbbVie for work on hepatitis C unrelated to this manuscript. Martyn Lloyd‐Jones has received honoraria for giving lectures and educational sessions organised by Indivior. Joseph Doyle’s institution has received investigator‐initiated research funding from Gilead Sciences and AbbVie and honoraria from Gilead Sciences and AbbVie.

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