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    The Virtual Inpatient Diabetes Management Service: COVID‐19 brings the future to inpatient diabetes management

    N Wah Cheung, Amanda Hor and Tien‐Ming Hng
    Med J Aust 2022; 216 (6): . || doi: 10.5694/mja2.51456
    Published online: 4 April 2022

    To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has strained health systems in New South Wales, and hospitals have rapidly adapted to care for inpatients with COVID‐19. In the 4 weeks leading up to 9 September 2021, 9330 locally acquired cases were diagnosed in Western Sydney alone.1

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      Barriers to accessing HIV pre‐exposure prophylaxis for Medicare‐ineligible people in Melbourne, Australia: analysis of patients attending the PrEPMe Clinic

      Vincent J Cornelisse, Jude Armishaw, Mike Catton, Dean Murphy and Edwina J Wright
      Med J Aust 2022; 216 (6): . || doi: 10.5694/mja2.51455
      Published online: 4 April 2022

      To the Editor: People without Medicare coverage cannot access Pharmaceutical Benefits Scheme (PBS)‐subsidised human immunodeficiency virus (HIV) pre‐exposure prophylaxis (PrEP) or associated clinical care. Rates of HIV infection diagnosis are disproportionately higher among overseas‐born gay and bisexual men compared with Australian‐born gay and bisexual men.1 In response, in June 2020, the Alfred Hospital and the Victorian Infectious Diseases Reference Laboratory established the free PrEPMe Clinic for Medicare‐ineligible people. Data were collected using proformas after patients provided verbal consent (Alfred Health Ethics Committee approval No. 656/18).

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      • 1 Alfred Hospital, Melbourne, VIC
      • 2 Monash University, Melbourne, VIC
      • 3 Victorian Infectious Diseases Reference Laboratory, Melbourne, VIC
      • 4 Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC
      • 5 Kirby Institute, UNSW Sydney, Sydney, NSW
      • 6 Burnet Institute, Melbourne, VIC


      Acknowledgements: 

      We thank Brian Price (Department of Infectious Diseases, Alfred Hospital) for assisting with the logistics of setting up the PrEPMe Clinic; and Ali Mafi (Commercial Road Pharmacy, Prahran) and Joseph Tesoriero (Health Smart Pharmacy, the Alfred Hospital) for providing advice on obtaining PrEP for Medicare‐ineligible people, and assisting with the practicalities of providing PrEP for PrEPMe patients. We also thank the team at www.pan.org.au, a not‐for‐profit organisation that assists people without Medicare to purchase PrEP online, as permitted by the Therapeutic Goods Administration’s Personal Importation Scheme. We acknowledge Jason Ong, who contributed by referring participants to the PrEPMe Clinic and is undertaking further research with PrEPMe participants. Edwina Wright has received funding from the Victorian, Tasmanian and the South Australian governments for the PrEPX study.

      Competing interests:

      Vincent Cornelisse has received speaker’s fees and advisory board fees from Gilead Sciences, and advisory board fees from ViiV Healthcare. Edwina Wright reports receipt of grants from Gilead Sciences (free study drug for the VicPrEP study, compensation to her institution for chairing a nursing education session and for attending an advisory board meeting, and uncompensated attendance for attending two Gilead meetings regarding listing of Truvada on the Australian Pharmaceutical Benefits Scheme); grants from Gilead Science and Merck Sharp and Dohme outside the submitted work; and financial support from Gilead Sciences, Abbott Laboratories, Janssen‐Cilag, Boehringer Ingelheim, ViiV Healthcare, and Merck Sharp and Dohme.

      • 1. Medland NA, Chow EPF, Read THR, et al. Incident HIV infection has fallen rapidly in men who have sex with men in Melbourne, Australia (2013–2017) but not in the newly‐arrived Asian‐born. BMC Infect Dis 2018; 18: 410.
      • 2. Traeger MW, Cornelisse VJ, Asselin J, et al. Association of HIV preexposure prophylaxis with incidence of sexually transmitted infections among individuals at high risk of HIV infection. JAMA 2019; 321: 1380–1390.
      • 3. Grulich AE, Jin F, Bavinton BR, et al. Long‐term protection from HIV infection with oral HIV pre‐exposure prophylaxis in gay and bisexual men: findings from the expanded and extended EPIC‐NSW prospective implementation study. Lancet HIV 2021; 8: e486–e494.
      • 4. Australian Government, Department of Health. Eighth National HIV Strategy; 2018–2022. https://www1.health.gov.au/internet/main/publishing.nsf/Content/ohp‐bbvs‐1/$File/HIV‐Eight‐Nat‐Strategy‐2018‐22.pdf (viewed Feb 2022).
      • 5. Australian Federation of AIDS Organisations. Agenda 2025 — ending HIV transmission in Australia. AFAO, 2021. https://www.afao.org.au/wp‐content/uploads/2021/06/Agenda‐25‐Technical‐Paper.pdf (viewed Feb 2022).
      • 6. Tran H, Saleem K, Lim M, et al. Global estimates for the lifetime cost of managing HIV. AIDS 2021; 35: 1273–1281.
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        Population DNA screening for medically actionable disease risk in adults

        Paul A Lacaze, Jane Tiller and Ingrid Winship, For the DNA Screen Investigator Group†
        Med J Aust 2022; 216 (6): . || doi: 10.5694/mja2.51454
        Published online: 4 April 2022

        Australia will take a world‐first step towards offering preventive DNA screening through the public health care system

        In adult‐onset genomic conditions, such as hereditary breast and ovarian cancer (HBOC), Lynch syndrome and familial hypercholesterolaemia, certain DNA variants confer high risk of developing future disease.1 DNA screening for these conditions could thereby identify medically actionable genetic risk factors, prompting timely risk management and informed decision making from early adulthood to facilitate early detection or prevention.2 Despite this opportunity, diagnostic rates for these conditions remain low,2,3,4 limited by restricted access to genetic testing and lack of awareness.

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        • 1 Monash University, Melbourne, VIC
        • 2 Royal Melbourne Hospital, Melbourne, VIC
        • 3 University of Melbourne, Melbourne, VIC


        Correspondence: paul.lacaze@monash.edu
        Acknowledgements: 

        Funding is provided by the Australian Government Department of Health, Medical Research Future Fund, Genomics Health Futures Mission (APP2009024).

        Competing interests:

        No relevant disclosures.

        • 1. Grzymski JJ, Elhanan G, Morales Rosado JA, et al. Population genetic screening efficiently identifies carriers of autosomal dominant diseases. Nat Med 2020; 26: 1235–1239.
        • 2. Breast Cancer Association Consortium; Dorling L, Carvalho S, Allen J, et al. Breast cancer risk genes — association analysis in more than 113 000 women. N Engl J Med 2021; 384: 428–439.
        • 3. Win AK, Jenkins MA, Dowty JG, et al. Prevalence and penetrance of major genes and polygenes for colorectal cancer. Cancer Epidemiol Biomarkers Prev 2017; 26: 404–412.
        • 4. Watts GF, Sullivan DR, Hare DL, et al. Integrated guidance for enhancing the care of familial hypercholesterolaemia in Australia. Heart Lung Circ 2021; 30: 324–349.
        • 5. Centers for Disease Control and Prevetion. Tier 1 genomics applications and their importance to public health. https://www.cdc.gov/genomics/implementation/toolkit/tier1.htm (viewed Feb 2022).
        • 6. Murray MF, Evans JP, Khoury MJ. DNA‐based population screening: potential suitability and important knowledge gaps. JAMA 2020; 323: 307–308.
        • 7. Standing Committee on Screening. Australian Population Based Screening Framework. Canberra: Australian Government, Department of Health; 2018. https://www.health.gov.au/sites/default/files/documents/2019/09/population‐based‐screening‐framework_0.pdf (viewed Feb 2022).
        • 8. Domchek SM, Friebel TM, Singer CF, et al. Association of risk‐reducing surgery in BRCA1 or BRCA2 mutation carriers with cancer risk and mortality. JAMA 2010; 304: 967–975.
        • 9. Rebbeck TR, Kauff ND, Domchek SM. Meta‐analysis of risk reduction estimates associated with risk‐reducing salpingo‐oophorectomy in BRCA1 or BRCA2 mutation carriers. J Natl Cancer Inst 2009; 101: 80–87.
        • 10. Burn J, Gerdes AM, Macrae F, et al. Long‐term effect of aspirin on cancer risk in carriers of hereditary colorectal cancer: an analysis from the CAPP2 randomised controlled trial. Lancet 2011; 378: 2081–2087.
        • 11. Manchanda R, Saridogan E, Abdelraheim A, et al. Annual outpatient hysteroscopy and endometrial sampling (OHES) in HNPCC/Lynch syndrome (LS). Arch Gynecol Obstet 2012; 286: 1555–1562.
        • 12. Versmissen J, Oosterveer DM, Yazdanpanah M, et al. Efficacy of statins in familial hypercholesterolaemia: a long term cohort study. BMJ 2008; 337: a2423.
        • 13. Manchanda R, Blyuss O, Gaba F, et al. Current detection rates and time‐to‐detection of all identifiable BRCA carriers in the Greater London population. J Med Genet 2018; 55: 538–545.
        • 14. Lynch Syndrome Australia. Misdiagnosed, misunderstood and missing out: Lynch syndrome Australia’s untold health story; 2017 https://lynchsyndrome.org.au/wp‐content/uploads/2017/03/Lynch‐Syndrome‐Report.pdf. (viewed Dec 2021).
        • 15. Rowley SM, Mascarenhas L, Devereux L, et al. Population‐based genetic testing of asymptomatic women for breast and ovarian cancer susceptibility. Genet Med 2018; 21: 913–922.
        • 16. Manickam K, Buchanan A, Schwartz MLB, et al. Exome sequencing‐based screening for BRCA1/2 expected pathogenic variants among adult biobank participants. JAMA Network Open 2018; 1: e182140.
        • 17. Buchanan AH, Lester Kirchner H, Schwartz MLB, et al. Clinical outcomes of a genomic screening program for actionable genetic conditions. Genet Med 2020; 22: 1874–1882.
        • 18. Willis AM, Terrill B, Pearce A, et al. My research results: a program to facilitate return of clinically actionable genomic research findings. Eur J Hum Genet 2021; https://doi.org/10.1038/s41431‐021‐00973‐z [Epub ahead of print].
        • 19. Tiller J, Winship I, Otlowski MFA, Lacaze PA. Monitoring the genetic testing and life insurance moratorium in Australia: a national research project. Med J Aust 2021; 214: 157–159. https://www.mja.com.au/journal/2021/214/4/monitoring‐genetic‐testing‐and‐life‐insurance‐moratorium‐australia‐national
        • 20. Zhang L, Bao Y, Riaz M, et al. Population genomic screening of all young adults in a health‐care system: a cost‐effectiveness analysis. Genet Med 2019; 21: 1958–1968.
        • 21. Marquina C, Lacaze P, Tiller J, et al. Population genomic screening of young adults for familial hypercholesterolaemia: a cost‐effectiveness analysis. Eur Heart J 2021; https://doi.org/10.1093/eurheartj/ehab770 [Epub ahead of print].
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          Passing on the Editor‐in‐Chief baton at the Medical Journal of Australia

          Nicholas J Talley
          Med J Aust 2022; 216 (5): . || doi: 10.5694/mja2.51434
          Published online: 21 March 2022

          “There is a Chinese curse which says ‘May he live in interesting times’. Like it or not, we live in interesting times. They are times of danger and uncertainty; but they are also the most creative of any time in the history of mankind.” — Robert F Kennedy, 1966

          As we continue to live through the COVID‐19 pandemic, climate change pressures including floods and fires, anti‐vaccine rhetoric, anti‐science sentiments and war in Ukraine, the words of Robert F Kennedy over 50 years ago ring true. Despite all the uncertainty, science and medicine have made tremendous strides in an unprecedented fashion, as exemplified by the very rapid development, testing and delivery of life‐saving vaccines for SARS‐CoV‐2. The past 2 years of the pandemic have reinforced how important high quality peer‐reviewed medical journals are as a trusted source of the best available information, in order to guide public health and the safe and effective practice of medicine.1 I am very proud of the role of the Medical Journal of Australia throughout the pandemic in publishing living guidelines, new research and evidence‐based viewpoints that have helped shape Australia’s response.1,2

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          • Editor‐in‐Chief, Medical Journal of Australia, Sydney, NSW


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

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

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            Preparing Australasian medical students for environmentally sustainable health care

            Diana L Madden, Graeme L Horton and Michelle McLean
            Med J Aust 2022; 216 (5): . || doi: 10.5694/mja2.51439
            Published online: 21 March 2022

            Medical educators and representatives of medical student associations in Australia and New Zealand are collaborating on an initiative on climate change and health in medical education

            Climate change and environmental degradation are harming the health of Australians and New Zealanders and pose a serious challenge to our health care systems.1,2 The World Health Organization in 2019 identified climate change and air pollution as the top threat to human health globally;3 a threat clearly visible in the sustained air pollution over south‐eastern Australia from bushfire smoke during the 2019–20 bushfire season. The health consequences of the bushfires and the associated prolonged, hazardous air quality prompted the Australian Medical Association and three medical colleges to declare climate change a public health emergency.4 Health care systems also contribute to climate change and environmental degradation. In Australia, health care contributes 7% of the country’s total carbon emissions and produces considerable waste which is either incinerated or sent to landfill.5 Despite these environmental challenges, there has been little response by medical programs to prepare medical graduates to manage the health impacts of climate change, and to practise environmentally sustainable health care. In 2018, we described an initiative to support medical educators and medical student organisations to work collaboratively to develop proposed learning objectives, curricula and learning resources addressing the health effects of climate change.6 This article describes the development of the model graduate outcome statements and learning objectives which have been shared with all medical schools in Australasia.

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            • 1 University of Notre Dame, Australia, Sydney, NSW
            • 2 University of Newcastle, Newcastle, NSW
            • 3 Bond University, Gold Coast, QLD


            Correspondence: lynne.madden@nd.edu.au
            Acknowledgements: 

            This article was written on behalf of the Climate Change and Health Working Group: Prof L Madden (Chair), University of Notre Dame Australia (Sydney); Prof M McLean, Bond University; A/Prof A Roiko, Griffith University; Prof A Woodward, University of Auckland; Dr G Horton, University of Newcastle; Prof I Haq, University of Sydney; Prof A Capon, Monash Sustainable Development Institute; Prof B Canny, Monash University; Dr J Maxwell, University of Melbourne; Prof A O’Sullivan, UNSW; Prof M Ackland, Monash University; Dr A MacMillan, University of Otago; Dr Isobelle Woodruff, formerly Australian Medical Students’ Association; Isabelle McKay, Australian Medical Students’ Association; Aaspreet Boparai, formerly New Zealand Medical Students’ Association (NZMSA); Kera Sherwood O’Regan, formerly NZMSA; Dr A Hankinson, University of Notre Dame Australia (Sydney); and since 2019: B Alsop‐ten Hove, NZMSA; E Yi, NZMSA; A/Prof L Selvey, University of Queensland; Dr C Slimings, Australian National University; Dr B Montgomery, University of Western Australia.

            Disclaimer:

            The statements or opinions expressed in this article reflect the views of the authors and do not represent the opinion or policies of Medical Deans Australia and New Zealand Inc.

            Competing interests:

            No relevant disclosures.

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              Parental consent and the treatment of transgender youth: the impact of Re Imogen

              Fiona Kelly, Simona Giordano, Michelle M Telfer and Ken C Pang
              Med J Aust 2022; 216 (5): . || doi: 10.5694/mja2.51431
              Published online: 21 March 2022

              Recent legal changes are negatively affecting provision of timely medical care to Australian transgender youth

              The number of transgender and gender diverse (henceforth, trans) youth seeking medical treatment has risen sharply over the past two decades in Australia and overseas.1,2 Unique legal requirements for consent to this treatment in Australia have developed through Family Court case law since 2004. Until recently, it was necessary for a young person seeking pubertal suppression or gender‐affirming hormone treatment to secure Family Court approval before treatment could commence, even in circumstances where both parents and the young person’s treating doctors supported treatment and considered it to be in their best interest, and the young person was deemed Gillick competent, which is achieved when a young person has “a sufficient understanding and intelligence to enable him or her to understand fully what is proposed”.3 The requirement for court approval was removed for puberty suppression in 2013 by Re Jamie,4 but the restrictions on gender‐affirming hormone treatment remained until the Full Family Court decision of Re Kelvin in 2017.5


              • 1 La Trobe University, Melbourne, VIC
              • 2 University of Manchester, Manchester, UK
              • 3 Royal Children's Hospital, Melbourne, VIC
              • 4 Murdoch Children’s Research Institute, Melbourne, VIC


              Correspondence: ken.pang@mcri.edu.au
              Acknowledgements: 

              Ken Pang is supported by the Royal Children's Hospital Foundation and the Hugh DT Williamson Foundation, neither of which had any role in the planning, writing or publication of this article.

              Competing interests:

              Michelle Telfer and Ken Pang are members of the Australian Professional Association for Trans Health.

              • 1. Pang KC, de Graaf NM, Chew D, et al. Association of media coverage of transgender and gender diverse issues with rates of referral of transgender children and adolescents to specialist gender clinics in the UK and Australia. JAMA Netw Open 2020; 3: e2011161.
              • 2. Wiepjes CM, Nota NM, de Blok CJM, et al. The Amsterdam Cohort of Gender Dysphoria Study (1972–2015): trends in prevalence, treatment, and regrets. J Sex Med 2018; 15: 582–590.
              • 3. Gillick v West Norfolk and Wisbech Area Health Authority [1986] AC 112.
              • 4. Re Jamie [2013] FamCAFC 110.
              • 5. Re Kelvin [2017] FamCAFC 258.
              • 6. Kelly F. “The court process is slow but biology is fast”: assessing the impact of the Family Court approval process on transgender children and their families. Aust J Family Law 2016; 30: 112.
              • 7. Telfer MM, Tollit MA, Pace CC, Pang KC. Australian standards of care and treatment guidelines for transgender and gender diverse children and adolescents. Med J Aust 2018; 209: 132–136. https://www.mja.com.au/journal/2018/209/3/australian‐standards‐care‐and‐treatment‐guidelines‐transgender‐and‐gender
              • 8. Re Imogen (No. 6) [2020] FamCA 761.
              • 9. O’Connell MA, Nguyen TP, Ahler A, et al. Approach to the patient: pharmacological management of trans and gender‐diverse adolescents. J Clin Endocrinol Metab 2021; 107: 241–257.
              • 10. Priest M. Transgender children and the right to transition: medical ethics when parents mean well but cause harm. Am J Bioeth 2019; 19: 45–59.
              • 11. Jowett S, Kelly F. Re Imogen: a step in the wrong direction. Aust J Family Law 2021; 34: 31–56.
              • 12. Secretary, Department of Health and Community Services v JWB and SMB (Marion’s case) (1992) 175 CLR 218.
              • 13. Young L. Mature minors and parenting disputes in Australia: engaging with the debate on best interests v autonomy. UNSW Law J 2019; 42: 1362–1364.
              • 14. A flawed agenda for trans youth [editorial]. Lancet Child Adolesc Health 2021; 5: 385.
              • 15. Bell and Mrs A v Tavistock and Portman NHS Trust [2020] EWHC 3274 (Admin).
              • 16. Davis LS. Transgender children and their parents struggle to cope with restrictive laws. CNN Health 2021; 22 June. https://edition.cnn.com/2021/06/14/health/trans‐kids‐care‐state‐bans‐wellness/index.html (viewed Feb 2022).
              • 17. Rew L, Young CC, Monge M, Bogucka R. Review: Puberty blockers for transgender and gender diverse youth‐a critical review of the literature. Child Adolesc Ment Health 2021; 26: 3–14.
              • 18. Mahfouda S, Moore JK, Siafarikas A, et al. Gender‐affirming hormones and surgery in transgender children and adolescents. Lancet Diabetes Endocrinol 2019; 7: 484–498.
              • 19. Simons L, Schrager SM, Clark LF, et al. Parental support and mental health among transgender adolescents. J Adolesc Health 2013; 53: 791–793.
              • 20. Australian Professional Association for Trans Health. AusPATH statement on medical gender affirmation and Re Imogen. 21 Sept 2020. https://auspath.org.au/2020/09/21/auspath‐statement‐on‐medical‐gender‐affirmation‐and‐re‐imogen/ (viewed Feb 2022).
              • 21. Tobin J, The UN Convention on the Rights of the Child: a commentary. Oxford University Press, 2019.
              • 22. UN Committee on the Rights of the Child. General Comment No 4 (2003): Adolescent health and development in the context of the Convention on the Rights of the Child (CRC/GC/2003/4). https://www.refworld.org/docid/4538834f0.html (viewed Feb 2022).
              • 23. Children’s Hospitals Australasia; Association for the Wellbeing of Children in Healthcare. Charter on the Rights of Children and Young People in Healthcare Services in Australia. 2017. https://children.wcha.asn.au/sites/default/files/australian_version_final_210911web.pdf (viewed Feb 2022).
              • 24. Clark BA, Virani A, Saewyc EM. “The edge of harm and help”: ethical considerations in the care of transgender youth with complex family situations. Ethics Behav 2020; 30: 161–180.
              • 25. Notini L, McDougall R, Pang KC. Should parental refusal of puberty‐blocking treatment be overridden? The role of the harm principle. Am J Bioeth 2019; 19: 69–72.
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                Responding to the rising number of suicides using barbiturates

                Bridin P Murnion and Darren M Roberts
                Med J Aust 2022; 216 (4): . || doi: 10.5694/mja2.51409
                Published online: 7 March 2022

                Suicide prevention requires ensuring that social media are responsible and accountable, and that poisoning surveillance systems are adequately supported

                Barbiturates have a narrow therapeutic index, and accidental or deliberate poisoning can cause coma and cardiorespiratory arrest. Barbiturate‐related death rates were high in the mid‐20th century, when barbiturates were still commonly prescribed, but safer alternatives mean that clinical indications for prescribing them are now extremely limited.1 Over the past twenty years, however, interest in barbiturates has increased, particularly in their use at the end of life.2


                • 1 Western Sydney Local Health District, Sydney, NSW
                • 2 The University of Sydney, Sydney, NSW
                • 3 Children's Hospital at Westmead, Sydney Children's Hospitals Network, Sydney, NSW
                • 4 Royal Prince Alfred Hospital, Sydney, NSW


                Competing interests:

                No relevant disclosures.

                • 1. Darke S, Chrzanowska A, Campbell G, et al. Barbiturate‐related hospitalisations, drug treatment episodes, and deaths in Australia, 2000–2018. Med J Aust 2022; 216: 194–198.
                • 2. Sinmyee S, Pandit VJ, Pascual JM, et al. Legal and ethical implications of defining an optimum means of achieving unconsciousness in assisted dying. Anaesthesia 2019; 74: 630–637.
                • 3. Campbell G, Darke S, Zahra E, et al. Trends and characteristics in barbiturate deaths Australia 2000–2019: a national retrospective study. Clin Toxicol (Phila) 2021; 59: 224–230.
                • 4. Queensland University of Technology. Voluntary assisted dying. Updated 23 Nov 2021. https://end‐of‐life.qut.edu.au/assisteddying (viewed Nov 2021).
                • 5. van den Hondel KE, Punt P, Dorn T, et al. The rise of suicides using a deadly dose of barbiturates in Amsterdam and Rotterdam, the Netherlands, between 2006 and 2017. J Forensic Leg Med 2020; 70: 101916.
                • 6. Ryan CJ, Callaghan S. Legal and ethical aspects of refusing medical treatment after a suicide attempt: the Wooltorton case in the Australian context. Med J Aust 2010; 193: 239–242. https://www.mja.com.au/journal/2010/193/4/legal‐and‐ethical‐aspects‐refusing‐medical‐treatment‐after‐suicide‐attempt
                • 7. Royal Australasian College of Physicians. Voluntary assisted dying. 2020. https://www.racp.edu.au/advocacy/policy‐and‐advocacy‐priorities/voluntary‐assisted‐dying (viewed Nov 2021).
                • 8. Jeste DV, Saks E. Decisional capacity in mental illness and substance use disorders: empirical database and policy implications. Behav Sci Law 2006; 24: 607–628.
                • 9. Evenblij K, Pasman HRW, Pronk R, Onwuteaka‐Philipsen BO. Euthanasia and physician‐assisted suicide in patients suffering from psychiatric disorders: a cross‐sectional study exploring the experiences of Dutch psychiatrists. BMC Psychiatry 2019; 19: 74.
                • 10. World Health Organization; International Association for Suicide Prevention. Preventing suicide: a resource for media professionals. Geneva: WHO, 2008. https://www.who.int/mental_health/prevention/suicide/resource_media.pdf (viewed Nov 2021).
                • 11. Brown J, Berling I, Jiranantakan T, et al. Toxicovigilance for suicide prevention following Internet promotion of sodium nitrite [abstract]. Injury Prev 2021; 27 (Suppl 2): A18‐A.
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                  Time for equal access to breast reduction surgery in Australia

                  Elisabeth Elder
                  Med J Aust 2022; 216 (3): . || doi: 10.5694/mja2.51386
                  Published online: 21 February 2022

                  Women with symptomatic macromastia need relief from a condition that can seriously impair their quality of life

                  In this issue of the MJA, Crittenden and colleagues report their cost–utility analysis of breast reduction surgery for women with symptomatic breast hypertrophy in Australia.1 Their key finding is that breast reduction surgery is cost‐effective, the cost per quality‐adjusted life‐year (QALY) being considerably lower than the recommended willingness to pay thresholds in the Australian health care system. The authors prospectively assessed health‐related quality of life (SF‐6D utility scores) for 209 women with symptomatic breast hypertrophy before and 12 months after breast reduction surgery. The SF‐6D, a six‐dimensional single health utility score, is derived from the Short Form‐36 (SF‐36), one of the most widely used instruments for assessing health‐related quality of life (range: 0 for death to 1 for perfect health). Their scores were compared with those for 124 women with similar symptoms who had not yet had reduction surgery. The mean SF‐6D scores were similar at baseline, and improved significantly for the women who had undergone surgery (0.313; standard deviation [SD], 0.263 to 0.626; SD, 0.277) but declined slightly (0.296; SD, 0.267 to 0.270; SD, 0.257) for those who had not. The effectiveness of the procedure was measured as the mean differential QALY gain (1.519; 95% confidence interval, 1.362–1.675), obtained at an incremental cost‐effectiveness ratio (ICER) of $7808 per QALY gained.


                  • Westmead Breast Cancer Institute, Sydney, NSW


                  Competing interests:

                  No relevant disclosures.

                  • 1. Crittenden TA, Ratcliffe J, Watson DI, et al. Cost‐utility analysis of breast reduction surgery for women with symptomatic breast hypertrophy. Med J Aust 2022; 216: 147–152.
                  • 2. Singh K, Losken A. Additional benefits of reduction mammaplasty: a systematic review of the literature. Plast Reconstr Surg 2012; 129: 562–570. PMID: 22090252
                  • 3. Crittenden T, Watson DI, Ratcliffe J, et al; AFESA Research Group. Does breast reduction surgery improve health‐related quality of life? A prospective cohort study in Australian women. BMJ Open 2020; 10: e031804.
                  • 4. Crittenden TA, Watson DI, Ratcliffe J, et al. Outcomes of breast reduction surgery using the BREAST‐Q: a prospective study and comparison with normative data. Plast Reconstr Surg 2019; 144: 1034–1044.
                  • 5. Lewin R, Liden M, Lundgren J, et al. Prospective evaluation of health after breast reduction surgery using the Breast‐Q, Short‐Form 36, Breast‐Related Symptoms Questionnaire, and Modified Breast Evaluation Questionnaire. Ann Plast Surg 2019; 83: 143–151.
                  • 6. Crittenden TA. Quality of life and other outcomes of breast reduction surgery [thesis]. Flinders University, Adelaide; Nov 2020. https://theses.flinders.edu.au/view/5f596e3a‐e41f‐4ca8‐bae8‐6f42d9b936f1/1 (viewed Dec 2021).
                  • 7. Widmark‐Jensen E, Bernhardsson S, Eriksson M, et al. A systematic review and meta‐analysis of risks and benefits with breast reduction in the public healthcare system: priorities for further research. BMC Surg 2021; 21: 343.
                  • 8. Winter R, Haug I, Lebo P, et al. Standardizing the complication rate after breast reduction using the Clavien–Dindo classification. Surgery 2017; 161: 1430–1435.
                  • 9. Krucoff KB, Carlson AB, Shammas RL, et al. Breast‐related quality of life in young reduction mammaplasty patients: a long‐term follow‐up using the BREAST‐Q. Plast Reconstr Surg 2019; 144: 743–750.
                  • 10. Australian Department of Health. Medicare Benefits Schedule: item 45523. MBS Online. http://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=45523&qt=ItemID (viewed Nov 2021).
                  • 11. Australian Department of Health. Medicare Benefits Schedule: item 45644. MBS Online. http://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=45644&qt=ItemID (viewed Nov 2021).
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                    Taking a broader view of the health care needs of people with chronic kidney disease

                    Kevan R Polkinghorne and Peter G Kerr
                    Med J Aust 2022; 216 (3): . || doi: 10.5694/mja2.51387
                    Published online: 21 February 2022

                    Older patients may never need kidney replacement therapy, but their other medical conditions require attention

                    Chronic kidney disease (CKD) is a public health problem worldwide.1 An estimated 1.7 million Australian adults, about 10% of the population, have biomedical signs of CKD,2 but more than half are unaware of their condition. People at particular risk include those over 60 years of age, Aboriginal and Torres Strait Islander people, and people with hypertension, diabetes mellitus, obesity, established cardiovascular disease, a personal history of acute kidney injury or smoking, or a family history of kidney disease. CKD is associated with higher all‐cause mortality, higher rates of cardiovascular disease, and reduced overall quality of life.3,4


                    • Monash Medical Centre, Melbourne, VIC


                    Correspondence: peter.kerr@monash.edu
                    Competing interests:

                    No relevant disclosures.

                    • 1. GBD Chronic Kidney Disease Collaboration. Global, regional, and national burden of chronic kidney disease, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2020; 395: 709–733.
                    • 2. Australian Institute of Health and Welfare. Chronic kidney disease (Cat. no. CDK 16). Updated 15 July 2020. https://www.aihw.gov.au/getmedia/0372ad7a‐7297‐4e7b‐a3e4‐5681c342ed2f/Chronic‐kidney‐disease.pdf.aspx?inline=true (viewed Sept 2021).
                    • 3. Levey AS, Coresh J. Chronic kidney disease. Lancet 2012; 379: 165–180.
                    • 4. Go AS, Chertow GM, Fan D, et al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004; 351: 1296–1305.
                    • 5. Keith DS, Nichols GA, Gullion CM, et al. Longitudinal follow‐up and outcomes among a population with chronic kidney disease in a large managed care organization. Arch Intern Med 2004; 164: 659–663.
                    • 6. Ravani P, Quinn R, Fiocco M, et al. Association of age with risk of kidney failure in adults with stage IV chronic kidney disease in Canada. JAMA Netw Open 2020; 3: e2017150.
                    • 7. Jose MD, Raj R, Jose K, et al. Competing risks of death and kidney failure in a cohort of Australian adults with severe chronic kidney disease. Med J Aust 2022; 216: 140–146
                    • 8. Cherney DZ, Repetto E, Wheeler DC, et al. Impact of cardio‐renal‐metabolic comorbidities on cardiovascular outcomes and mortality in type 2 diabetes mellitus. Am J Nephrol 2020; 51: 74–82.
                    • 9. Australia and New Zealand Dialysis and Transplant Registry. 42nd report, chapter 3: Mortality in end stage kidney disease. Adelaide: ANZDATA, 2019. https://www.anzdata.org.au/wp‐content/uploads/2019/09/c03_mortality_2018_ar_2019_v1.0_20191202.pdf (viewed Dec 2021).
                    • 10. Foote C, Kotwal S, Gallagher M, et al. Survival outcomes of supportive care versus dialysis therapies for elderly patients with end‐stage kidney disease: a systematic review and meta‐analysis. Nephrology 2016; 21: 241–253.
                    • 11. Kidney Health Australia. Chronic kidney disease (CKD) management in primary care. 4th edition. Melbourne: Kidney Health Australia, 2020. https://kidney.org.au/health‐professionals/ckd‐management‐handbook (viewed Sept 2021).
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                      Acting on better data for general medical care will help solve our acute hospital access crisis

                      Harvey H Newnham
                      Med J Aust 2022; 216 (3): . || doi: 10.5694/mja2.51385
                      Published online: 21 February 2022

                      Smarter measures for general medicine are needed to improve hospital access

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                      • 1 Alfred Health, Melbourne, VIC
                      • 2 Monash University, Melbourne, VIC


                      Correspondence: H.Newnham@alfred.org.au
                      Acknowledgements: 

                      I thank my many colleagues clinical and non‐clinical from local, national and international units and boards who have contributed to the ideas discussed in this article: in particular, Richard Coates, Daniel Fineberg, Felice Borghmans, Lara Kimmel and Andrew Way of Alfred Health for creating space for, and leading, conversations that matter.

                      Competing interests:

                      No relevant disclosures.

                      Online responses are no longer available. Please refer to our instructions for authors page for more information.
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