Topics

AI‐based tools can help with image acquisition, reconstruction and quality; interpretation, diagnosis and decision support; and manual tasks

Artificial intelligence (AI) is having a disruptive impact in many areas, including health care. In medicine, machine learning (ML) techniques have existed for decades but were mostly not adopted. New deep learning techniques, along with copious medical imaging and digital health data, now provide standardised, reproducible, dependable and accurate diagnostic reports. These can only improve patient care and safety, enhancing the practice of clinical medicine. However, a number of challenges have arisen, hindering progress and more widespread application. In this article, we describe current AI/ML tools in medical imaging, discuss the major challenges facing the field, and offer some potential solutions.

1 Alfred Health, Melbourne, VIC
2 Monash University, Melbourne, VIC
3 Alfred Hospital, Melbourne, VIC
4 Weill Cornell Medicine, New York, NY, USA

Correspondence: meng.law@alfred.org.au

Competing interests:

No relevant disclosures.

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Position statement

National Heart Foundation of Australia: position statement on coronary artery calcium scoring for the primary prevention of cardiovascular disease in Australia

Garry LR Jennings, Ralph Audehm, Warrick Bishop, Clara K Chow, Siaw-Teng Liaw, Danny Liew and Sara M Linton

Med J Aust 2021; 214 (9): . || doi: 10.5694/mja2.51039
Published online: 17 May 2021

Topics

Cardiovascular diseases

General medicine

Diagnostic techniques and procedures

Abstract

Introduction: This position statement considers the evolving evidence on the use of coronary artery calcium scoring (CAC) for defining cardiovascular risk in the context of Australian practice and provides advice to health professionals regarding the use of CAC scoring in primary prevention of cardiovascular disease in Australia.

Main recommendations:

CAC scoring could be considered for selected people with moderate absolute cardiovascular risk, as assessed by the National Vascular Disease Prevention Alliance (NVDPA) absolute cardiovascular risk algorithm, and for whom the findings are likely to influence the intensity of risk management. (GRADE evidence certainty: Low. GRADE recommendation strength: Conditional.)
CAC scoring could be considered for selected people with low absolute cardiovascular risk, as assessed by the NVDPA absolute cardiovascular risk algorithm, and who have additional risk-enhancing factors that may result in the underestimation of risk. (GRADE evidence certainty: Low. GRADE recommendation strength: Conditional.)
If CAC scoring is undertaken, a CAC score of 0 AU could reclassify a person to a low absolute cardiovascular risk status, with subsequent management to be informed by patient–clinician discussion and follow contemporary recommendations for low absolute cardiovascular risk. (GRADE evidence certainty: Very low. GRADE recommendation strength: Conditional.)
If CAC scoring is undertaken, a CAC score > 99 AU or ≥ 75th percentile for age and sex could reclassify a person to a high absolute cardiovascular risk status, with subsequent management to be informed by patient–clinician discussion and follow contemporary recommendations for high absolute cardiovascular risk. (GRADE evidence certainty: Very low. GRADE recommendation strength: Conditional.)

Changes in management as a result of this statement: CAC scoring can have a role in reclassification of absolute cardiovascular risk for selected patients in Australia, in conjunction with traditional absolute risk assessment and as part of a shared decision‐making approach that considers the preferences and values of individual patients.

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1 University of Sydney, Sydney, NSW
2 National Heart Foundation of Australia, Melbourne, VIC
3 General Practice and Primary Health Care Academic Centre, University of Melbourne, Melbourne, VIC
4 Calvary Health Care Tasmania Lenah Valley Campus, Hobart, TAS
5 Westmead Hospital, Sydney, NSW
6 UNSW Sydney, Sydney, NSW
7 Ingham Institute of Applied Medical Research, Sydney, NSW
8 Monash University, Melbourne, VIC
9 Royal Melbourne Hospital, Melbourne, VIC

Correspondence: garry.jennings@sydney.edu.au

Acknowledgements:

Funding and coordination were provided by the National Heart Foundation of Australia. Expert reference group members contributed to the technical content on an advisory basis. The position statement manuscript and GRADE evidence appraisal were prepared by the National Heart Foundation of Australia.

Competing interests:

Warrick Bishop receives consultancy fees to report on coronary artery calcium scoring test results, and has written a book on the subject. He is paid membership fees for his website, which provides information about heart attack prevention. Clara Chow receives consultancy fees to report on coronary artery calcium scoring test results. Danny Liew receives honoraria to conduct cost‐effective analyses for pharmaceutical companies.

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Editorials

Lessons from the United Kingdom’s COVID‐19 vaccination strategy

Anthony Harnden and Andrew Earnshaw

Med J Aust 2021; 214 (9): . || doi: 10.5694/mja2.51042
Published online: 17 May 2021

Topics

Infectious diseases

The predominantly age‐based structure of the British vaccination program has enabled a rapid delivery with high vaccine uptake

The United Kingdom has been profoundly affected by the coronavirus disease 2019 (COVID‐19) pandemic. In our population of over 66 million, to date we have had over 4.3 million confirmed infections with over 127 000 deaths (10 April 2021).1 Vaccination has provided an opportunity to limit the impact of COVID‐19 on our population and hopefully reduce the risk of significant mortality in any third wave.

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1 University of Oxford, Oxford, UK
2 United Kingdom Joint Committee on Vaccination and Immunisation, National Immunization Technical Advisory Groups, London, UK

Correspondence: anthony.harnden@phc.ox.ac.uk

Competing interests:

Anthony Harnden is Deputy Chair and Andrew Earnshaw is Head of the UK Joint Committee on Vaccination and Immunisation.

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Editorials

The challenges of managing both chronic pain and opioid use in general practice

Hester Wilson

Med J Aust 2021; 214 (9): . || doi: 10.5694/mja2.51041
Published online: 17 May 2021

Topics

General medicine

Anesthesia, analgesia and pain

Substance-related disorders

The safety and value of reducing opioid use are recognised, but difficult conversations and less accessible alternatives are barriers

Chronic pain affects about 20% of adults in Australia and New Zealand,1,2 and opioids have been enthusiastically embraced for treating it. Unfortunately, this has led to significant harm,3,4,5 and evidence of the long term effectiveness of opioids for relieving chronic pain is limited.3,6

1 The Langton Centre, Sydney, NSW
2 University of New South Wales, Sydney, NSW
3 Alice St General Practice, Sydney, NSW

Correspondence: Hester.Wilson@health.nsw.gov.au

Competing interests:

I have no connections with the tobacco, alcohol or gaming industries. I have received funding for consultancies or for serving on expert advisory panels from Indivior, Lundbeck, Seqirus, Mundipharma, and Pfizer.

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2. New Zealand Ministry of Health. New Zealand Health Survey: annual data explorer 2019/20. Adults/topic: other health conditions. Nov 2020. https://minhealthnz.shinyapps.io/nz-health-survey-2019-20-annual-data-explorer/_w_15f47ab5/#!/explore-topics (viewed Feb 2021).
3. Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health pathways to prevention workshop. Ann Intern Med 2015; 162: 276–286.
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5. Australian Institute of Health and Welfare. Opioid harm in Australia and comparisons between Australia and Canada. (AIHW Cat. no. HSE 210). Canberra: AIHW, 2018. https://www.aihw.gov.au/getmedia/605a6cf8-6e53-488e-ac6e-925e9086df33/aihw-hse-210.pdf.aspx?inline=true (viewed Feb 2021).
6. Krebs EE, Gravely A, Nugent S, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the space randomized clinical trial. JAMA 2018; 319: 872–882.
7. Tardif H, Hayes C, Allingham SF. Opioid cessation is associated with reduced pain and improved function in people attending specialist chronic pain services. Med J Aust 2021; 214: 430–432.
8. Matthias MS, Johnson NL, Shields CG, et al. “I’m not gonna pull the rug out from under you”: patient-provider communication about opioid tapering. J Pain 2017; 18: 1365–1373.
9. Webster F, Rice K, Katz J, et al. An ethnography of chronic pain management in primary care: the social organization of physicians’ work in the midst of the opioid crisis. PLoS One 2019; 14: e0215148.
10. Matthias MS, Krebs EE, Collins LA, et al. “I’m not abusing or anything”: patient–physician communication about opioid treatment in chronic pain. Patient Educ Couns 2013; 93: 197–202.
11. Prathivadi P, Barton C, Mazza D. Qualitative insights into the opioid prescribing practices of Australian GP. Fam Pract 2020; 37: 412–417.
12. Dunn E. Breaking the pain barrier. Medical Observer [online], 1 June 2018. https://www.apsoc.org.au/PDF/Other_Pain_Resources/20180601_Medical_Observer_Breaking-Pain-Barrier_JUN18.pdf (viewed Mar 2021).
13. Australian Department of Health. Chronic disease management: allied health individual services. Updated 10 Apr 2014. https://www1.health.gov.au/internet/main/publishing.nsf/Content/Chronic+Disease+Allied+Health+Individual+Services (viewed Mar 2021).
14. Bennett C. The impact of pain on rural and regional Australia: problems and solutions [abstract]. National Rural Health Conference, Hobart, Tasmania, 24–27 March 2019. https://www.ruralhealth.org.au/15nrhc/sites/default/files/B2-1_Bennett.pdf (viewed Mar 2021).

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Perspectives

Introducing general practice enrolment in Australia: the devil is in the detail

Michael Wright and Roald Versteeg

Med J Aust 2021; 214 (9): . || doi: 10.5694/mja2.51027
Published online: 17 May 2021

Topics

General medicine

Health services administration

Enrolment may strengthen the link between patients and their preferred primary care providers and needs to support flexible provision of high quality care

In the 2019–20 federal budget, $448 million was allocated to introduce a system of voluntary general practice enrolment for Indigenous people over 50 years of age and all Australians over 70 years of age from July 2020.1 Enrolment, also known as nomination or empanelment, allows patients to register with a specified general practitioner at their preferred general practice. At the end of June 2020, the federal government announced that the introduction of voluntary general practice enrolment would be delayed and that models to support universal enrolment would be explored as part of the development of a 10‐year primary health care plan.2 The exploration of population‐wide enrolment was prompted by Australia’s coronavirus disease 2019 (COVID‐19) response, most notably the introduction of Medicare‐funded telehealth (both telephone and video consultations) — a long‐advocated reform currently available until 30 June 2021. In this article, we outline Australian and international experience with enrolment and suggest ways for Australia to introduce a system that benefits patients, health system funders and providers of comprehensive holistic general practice care.

1 Centre for Health Economics Research and Evaluation, University of Technology, Sydney, NSW
2 Royal Australian College of General Practitioners, Melbourne, VIC

Correspondence: michael.wright@chere.uts.edu.au

Competing interests:

Michael Wright chairs the Royal Australian College of General Practitioners (RACGP) Expert Committee on Funding and Health System Reform, chairs the Board of the Central and Eastern Sydney Primary Health Network, was a member of the Primary Health Care Advisory Group and has advisory roles with the Australian Institute of Health and Welfare. Roald Versteeg is employed by the RACGP.

1. Budget 2019–20. Budget Paper No. 2: Budget Measures 2019–20. Canberra: Commonwealth of Australia, 2019. https://budget.gov.au/2019-20/content/bp2/index.htm (viewed Apr 2021).
2. Australian Government Department of Health. Voluntary patient enrolment. Updated 18 March 2021. https://www1.health.gov.au/internet/main/publishing.nsf/Content/voluntary-patient-enrolment-for-older-australians (viewed Apr 2021).
3. Wright M, Hall J, van Gool K, et al. How common is multiple general practice attendance? Aust J Gen Pract 2018; 47: 289–296.
4. Primary Health Care Advisory Group. Better outcomes for people with chronic and complex health conditions. Canberra: Commonwealth of Australia, 2016. http://www.health.gov.au/internet/main/publishing.nsf/Content/76B2BDC12AE54540CA257F72001102B9/$File/Primary-Health-Care-Advisory-Group_Final-Report.pdf (viewed Mar 2020).
5. Medicare Benefits Schedule Review Taskforce. Taskforce findings: General Practice and Primary Care Clinical Committee Report. Canberra: Commonwealth of Australia, 2020. https://www.health.gov.au/resources/publications/taskforce-findings-general-practice-and-primary-care-clinical-committee-report (viewed Apr 2021).
6. Australian Government Department of Health. Evaluation report of the Diabetes Care Project. Canberra: Commonwealth of Australia, 2015. https://www.health.gov.au/sites/default/files/documents/2019/09/evaluation-of-the-diabetes-care-project-evaluation-report-of-the-diabetes-care-project.pdf (viewed Apr 2021).
7. Australian Government Department of Health and Ageing. The national evaluation of the second round of Coordinated Care Trials: final report. Canberra: Commonwealth of Australia, 2007. https://apo.org.au/sites/default/files/resource-files/2008-04/apo-nid8664.pdf (viewed Apr 2021).
8. Kalucy L, Katterl R, Jackson‐Bowers E, et al. Models of patient enrolment (PHC RIS Policy Issue Review). Adelaide: Primary Health Care Research and Information Service, 2009. https://dspace2.flinders.edu.au/xmlui/bitstream/handle/2328/26593/PIR%20May%2009.pdf?sequence=1&isAllowed=y (viewed Mar 2021).
9. Taylor CJ, Wright M, Jackson CL, et al. Grass is greener? General practice in England and Australia. Br J Gen Pract 2016; 66: 428–429.
10. van Walraven C, Oake N, Jennings A, Forster AJ. The association between continuity of care and outcomes: a systematic and critical review. J Eval Clin Pract 2010; 16: 947–956.
11. Pereira Gray DJ, Sidaway‐Lee K, White E, et al. Continuity of care with doctors—a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open 2018; 8: e021161.
12. Adler R, Vasiliadis A, Bickell N. The relationship between continuity and patient satisfaction: a systematic review. Fam Pract 2010; 27: 171–178.
13. Hueston WJ. Does having a personal physician improve quality of care in diabetes? J Am Board Fam Med 2010; 23: 82–87.
14. Blewett LA, Johnson PJ, Lee B, et al. When a usual source of care and usual provider matter: adult prevention and screening services. J Gen Intern Med 2008; 23: 1354–1360.
15. Wetmore S, Boisvert L, Graham E, et al. Patient satisfaction with access and continuity of care in a multidisciplinary academic family medicine clinic. Can Fam Physician 2014; 60: e230–e236.
16. Cheng SH, Chen CC. Effects of continuity of care on medication duplication among the elderly. Med Care 2014; 52: 149–156.
17. Mainous AG 3rd, Koopman RJ, Gill JM, et al. Relationship between continuity of care and diabetes control: evidence from the third national health and nutrition examination survey. Am J Public Health 2004; 94: 66–70.
18. Wright M, Versteeg R, Hall J. General practice’s early response to the COVID‐19 pandemic. Aust Health Rev 2020; 44: 733–736.
19. Tiagi R, Chechulin Y. The effect of rostering with a patient enrolment model on emergency department utilization. Healthc Policy 2014; 9: 105–121.
20. Singh J, Dahrouge S, Green ME. The impact of the adoption of a patient rostering model on primary care access and continuity of care in urban family practices in Ontario, Canada. BMC Fam Pract 2019; 20: 52.
21. Glazier RH, Kopp A, Schultz SE, et al. All the right intentions but few of the desired results: lessons on access to primary care from ontario’s patient enrolment models. Healthc Q 2012; 15: 17–21.
22. Wensing M, Kolle PK, Szecsenyi J, et al. Effects of a program to strengthen general practice care on hospitalisation rates: a comparative observational study. Scand J Prim Health Care 2018; 36: 109–114.
23. Tammes P, Payne RA, Salisbury C, et al. The impact of a named GP scheme on continuity of care and emergency hospital admission: a cohort study among older patients in England, 2012–2016. BMJ Open 2019; 9: e029103.

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Editorials

Health for all by 2030 is within our grasp: we must act now

Sandro Demaio

Med J Aust 2021; 214 (8): . || doi: 10.5694/mja2.51018
Published online: 3 May 2021

Topics

Environment and public health

Health services administration

Australia has a once‐in‐a-lifetime opportunity to create a healthy, sustainable, equitable and prosperous future by taking bold action to build back better, fairer and greener after the coronavirus pandemic

Australia is considered a coronavirus disease 2019 (COVID‐19) success story by international standards,1 notwithstanding the significant health and economic impacts experienced across the country. The level of pandemic‐induced disruption has been profound, with COVID‐19 catapulting us all, as individuals and communities, into new ways of being.

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1 Victorian Health Promotion Foundation, Melbourne
2 University of Melbourne, Melbourne

Correspondence: sdemaio@vichealth.vic.gov.au

Competing interests:

No relevant disclosures.

1. Margo J. WHO expert explains Australia’s pandemic success. Australian Financial Review 2021; 15 Jan. https://www.afr.com/policy/health-and-education/who-expert-explains-australia-s-pandemic-success-20210114-p56u8w (viewed Mar 2021).
2. World Health Organization. WHO Director‐General’s opening remarks at the media briefing on. COVID‐19 – 11 March 2020. https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020 (viewed Mar 2021).
3. Klapdor M. COVID‐19 economic response – free child care. Parliament of Australia, 6 Apr 2020; amended 19 May 2020. https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/FlagPost/2020/April/Coronavirus_response-Free_child_care (viewed Mar 2021).
4. Parsell C, Clarke A, Kuskoff E. Understanding responses to homelessness during COVID‐19: an examination of Australia. Housing Stud 2020; https://doi.org/10.1080/02673037.2020.1829564.
5. Arthur D. COVID‐19 economic response – wage subsidies aim to put workplaces into hibernation. Parliament of Australia, 6 Apr 2020. https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/FlagPost/2020/April/Coronavirus-Response-Wage-Subsidies (viewed Mar 2021).
6. Victorian Health Promotion Foundation. VicHealth coronavirus wellbeing impact study: follow‐up survey. Melbourne: VHPF, 2020. https://www.vichealth.vic.gov.au/media-and-resources/publications/vichealth-coronavirus-victorian-wellbeing-impact-study-follow-up-survey#; (viewed Mar 2021).
7. Australian Government Department of Health. COVID‐19 National Health Plan – Primary Care – MBS telehealth items staged rollout [fact sheet]. 24 Mar 2020. https://www.health.gov.au/resources/publications/covid-19-national-health-plan-primary-care-mbs-telehealth-items-staged-rollout (viewed Mar 2021).
8. Bendle S. Around the traps: 15 things to note for a new crisis, Croakey 2020; 4 June. https://www.croakey.org/around-the-traps-15-things-to-note-for-a-new-crisis/ (viewed Mar 2021).
9. Russell L. Australia’s health care after coronavirus – is there a silver lining to the pandemic? Pearls and Irritations: John Menadue’s Public Policy Journal; 3 July 2020. https://johnmenadue.com/lesley-russell-australias-health-care-after-coronavirus-is-there-a-silver-lining-to-the-pandemic/ (viewed Mar 2021).
10. Australian Institute of Health and Welfare. Indigenous Australians. https://www.aihw.gov.au/reports-data/population-groups/indigenous-australians/overview (viewed Mar 2021).
11. Horne R, Willand N, Dorignon L, Middha B. The lived experience of COVID‐19: housing and household resilience (AHURI Final Report No. 345). Melbourne: Australian Housing and Urban Research Institute, 2020. https://www.ahuri.edu.au/research/final-reports/345 (viewed Mar 2021).
12. Backholer K, Baum F, Finlay S, et al. Australia in 2030: what is our path to health for all? Med J Aust 2021; 214 (8 Suppl): S1‐S40.

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Editorials

The increasing burden of inflammatory bowel disease

Edward V Loftus

Med J Aust 2021; 214 (8): . || doi: 10.5694/mja2.51001
Published online: 3 May 2021

Topics

Digestive system diseases

Until we reach “prevalence equilibrium”, even small increases in incidence eventually result in higher prevalence

When I attended medical school in the 1980s, we were taught that ulcerative colitis and Crohn disease were conditions seen in white people in highly developed regions such as northern Europe, the United Kingdom and some Commonwealth nations, and North America. Over the past four decades, the incidence of inflammatory bowel disease (IBD) across geographic regions and ethnic groups has risen sharply.1 The global burden of IBD, which can substantially reduce quality of life, is clearly increasing.2 Patients with IBD often require expensive medications or procedures,3 have higher rates of anxiety and depression,4 and are more likely to have disabilities.5

Mayo Clinic, Rochester, MN, United States of America

Correspondence: loftus.edward@mayo.edu

Competing interests:

I have provided consultation services to AbbVie, Amgen, Allergan, Boehringer Ingelheim, Bristol‐Myers Squibb, Celgene, Celltrion Healthcare, Eli Lilly, Genentech, Gilead, Iterative Scopes, Janssen, Ono Pharma, Pfizer, Takeda, and UCB. I have received research support from AbbVie, Amgen, Bristol‐Myers Squibb, Celgene, Genentech, Gilead, Janssen, Pfizer, Receptos, Robarts Clinical Trials, Takeda, and UCB. I am a shareholder in Exact Sciences.

1. Ng SC, Shi HY, Hamidi N, et al. Worldwide incidence and prevalence of inflammatory bowel disease in the 21st century: a systematic review of population-based studies. Lancet 2017; 390: 2769–2778.
2. GBD 2017 Inflammatory Bowel Disease Collaborators. The global, regional, and national burden of inflammatory bowel disease in 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet Gastroenterol Hepatol 2020; 5: 17-30.
3. Park KT, Ehrlich OG, Allen JI, et al. The cost of inflammatory bowel disease: an initiative from the Crohn’s & Colitis Foundation. Inflamm Bowel Dis 2020; 26: 1–10.
4. Szigethy EM, Allen JI, Reiss M, et al. White paper AGA: the impact of mental and psychosocial factors on the care of patients with inflammatory bowel disease. Clin Gastroenterol Hepatol 2017; 15: 986–997.
5. Lo B, Prosberg MV, Gluud LL, et al. Systematic review and meta-analysis: assessment of factors affecting disability in inflammatory bowel disease and the reliability of the inflammatory bowel disease disability index. Aliment Pharmacol Ther 2018; 47: 6–15.
6. Freeman J, Hutchison GB. Prevalence, incidence and duration. Am J Epidemiol 1980; 112: 707–723.
7. Shivashankar R, Tremaine WJ, Harmsen WS, Loftus EV. Incidence and prevalence of Crohn’s disease and ulcerative colitis in Olmsted County, Minnesota from 1970 through 2010. Clin Gastroenterol Hepatol 2017; 15: 857–863.
8. Aniwan S, Harmsen WS, Tremaine WJ, et al. Overall and cause-specific mortality of inflammatory bowel disease in Olmsted County, Minnesota, from 1970 through 2016. Mayo Clin Proc 2018; 93: 1415–1422.
9. Kaplan GG. The global burden of IBD: from 2015 to 2025. Nat Rev Gastroenterol Hepatol 2015; 12: 720–727.
10. Kaplan GG, Bernstein CN, Coward S, et al. The impact of inflammatory bowel disease in Canada 2018: epidemiology. J Can Assoc Gastroenterol 2019; 2(Suppl 1): S6–S16.
11. Jones GR, Lyons M, Plevris N, et al. IBD prevalence in Lothian, Scotland, derived by capture-recapture methodology. Gut 2019; 68: 1953–1960.
12. Pudipeddi A, Liu J, Kariyawasam V, et al. High prevalence of Crohn disease and ulcerative colitis among older people in Sydney. Med J Aust 2021; 214: 365–370.
13. Mahid SS, Minor KS, Soto RE, et al. Smoking and inflammatory bowel disease: a meta-analysis. Mayo Clin Proc 2006; 81: 1462–1471.
14. Peppercorn MA. The overlap of inflammatory bowel disease and diverticular disease. J Clin Gastroenterol 2004; 38(Suppl 1): S8–S10.
15. Thia KT, Loftus EV, Sandborn WJ, Yang SK. An update on the epidemiology of inflammatory bowel disease in Asia. Am J Gastroenterol 2008; 103: 3167–3182.
16. Ng SC, Tang W, Ching JY, et al. Incidence and phenotype of inflammatory bowel disease based on results from the Asia-Pacific Crohn’s and Colitis Epidemiology Study. Gastroenterology 2013; 145: 158–165.
17. Charpentier C, Salleron J, Savoye G, et al. Natural history of elderly-onset of inflammatory bowel disease: a population-based cohort study. Gut 2014; 63: 423–432.
18. Piovani D, Danese S, Peyrin-Biroulet L, et al. Systematic review with meta-analysis: biologics and risk of infection or cancer in elderly patients with inflammatory bowel disease. Aliment Pharmacol Ther 2020; 51: 820–830.
19. Nguyen GC, Targownik LE, Singh H, et al. The impact of inflammatory bowel disease in Canada 2018: IBD in seniors. J Can Assoc Gastroenterol 2109; 2(Suppl 1): S68-S72.
20. Kochar B, Cai W, Cagan A, Ananthakrishnan AN. Pretreatment frailty is independently associated with increased risk of infections after immunosuppression in patients with inflammatory bowel diseases. Gastroenterology 2020; 158: 2104–2111.
21. Qian AS, Nguyen NH, Elia J, et al. Frailty is independently associated with mortality and readmission in hospitalized patients with inflammatory bowel diseases. Clin Gastroenterol Hepatol 2020; https://doi.org/10.1016/j.cgh.2020.08.010 [online ahead of print].
22. Kaplan GG, Windsor JW. The four epidemiological stages of the global evolution of inflammatory bowel disease. Nat Rev Gastroenterol Hepatol 2021; 18: 56–66.

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Editorials

Lack of efficacy of cannabidiol for relieving back pain: time to re‐set expectations?

Chris Hayes and Jennifer H Martin

Med J Aust 2021; 214 (8): . || doi: 10.5694/mja2.51025
Published online: 3 May 2021

Topics

Pharmaceutical preparations

Musculoskeletal diseases

Anesthesia, analgesia and pain

In the absence of evidence of benefit for acute low back pain, its over‐the‐counter availability should be reconsidered

Decades of opioid overuse can teach us valuable lessons about how we should handle medicinal cannabinoids, including cannabidiol (CBD). One major lesson is that access to medicines should not move ahead of scientific evidence. Over time, evidence that context is critical has accumulated: using opioids to treat acute pain and cancer pain, in the management of opioid dependency, and in palliative care can be justified. However, the indication creep from acute to chronic non‐cancer pain was unwarranted. Consequently, clinicians are sensitive to new pain medicines being made available without evidence of benefit, and the motivations for accelerated access have been questioned.1

1 Hunter Integrated Pain Service, Hunter New England Local Health Districts, Newcastle, NSW
2 Centre for Drug Repuposing and Medicines Research, University of Newcastle, Newcastle, NSW

Correspondence: Chris.Hayes@health.nsw.gov.au

Competing interests:

Jennifer Martin has a relative who is the chief medical officer of CannaPacific, a company licensed to grow cannabis; she herself has no financial or administrative involvement with the company.

1. Bell RF, Kalso EA. Cannabinoids for pain or profit? Pain 2020; https://doi.org/10.1097/j.pain.0000000000001930 [online ahead of print].
2. Therapeutic Goods Administration. Medicinal cannabis: role of the TGA [website]. Mar 2021. https://www.tga.gov.au/medicinal-cannabis-role-tga (viewed Mar 2021).
3. Fisher E, Moore RA, Fogarty AEW, et al. Cannabinoids, cannabis, and cannabis‐based medicines for pain management. Pain 2020; https://doi.org/10.1097/j.pain.0000000000001929 [online ahead of print].
4. Stockings E, Campbell G, Hall W, et al. Cannabis and cannabinoids for the treatment of people with chronic noncancer pain conditions: a systematic review and meta‐analysis of controlled and observational studies. Pain 2018; 159: 1932–1954.
5. McCartney D, Benson MJ, Desbrow B, et al. Cannabidiol and sports performance: a narrative review of relevant evidence and recommendations for future research. Sports Med Open 2020; 6: 27.
6. Chesney E, Oliver D, Green A, et al. Adverse effects of cannabidiol: a systematic review and meta‐analysis of randomized clinical trials. Neuropsychopharmacol 2020; 45: 1799–1806.
7. Huestis MA, Solimini R, Pichini S, et al. Cannabidiol adverse effects and toxicity. Curr Neuropharmacol 2019; 17: 974–989.
8. Senate Standing Committees on Community Affairs. Current barriers to patient access to medicinal cannabis in Australia. https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Medicinalcannabis (viewed Mar 2021).
9. Therapeutic Goods Administration. Proposed amendments to the Poisons Standard: joint ACMS/ACCS meetings, June 2020. Apr 2020. https://www.tga.gov.au/consultation-invitation/consultation-proposed-amendments-poisons-standard-joint-acmsaccs-meetings-june-2020 (viewed Mar 2021).
10. Therapeutic Goods Administration. Over-the‐counter access to low dose cannabidiol [media release]. 15 Dec 2020. https://www.tga.gov.au/media-release/over-counter-access-low-dose-cannabidiol (viewed Mar 2021).
11. Millar SA, Stone NL, Bellman ZD, et al. A systematic review of cannabidiol dosing in clinical populations. Br J Clin Pharmacol 2019; 85: 1888–1900.
12. Kocis PT, Vrana KE. Delta‐9-tetrahydrocannabinol and cannabidiol drug–drug interactions. Med Cannabis Cannabinoids 2020; 3: 61–73.
13. Bebee B, Taylor DM, Bourke E, et al. The CANBACK trial: a randomised, controlled clinical trial of oral cannabidiol for people presenting to the emergency department with acute low back pain. Med J Aust 2021; 214: 370–375.
14. Manini AF, Yiannoulos G, Bergamaschi MM, et al. Safety and pharmacokinetics of oral cannabidiol when administered concomitantly with intravenous fentanyl in humans. J Addict Med 2015; 9: 204–210.

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Editorials

Evidence‐based care to support longer, healthier lives for cancer survivors

Emily Banks and Grace Joshy

Med J Aust 2021; 214 (7): . || doi: 10.5694/mja2.50995
Published online: 19 April 2021

Topics

Neoplasms

Health services administration

Statistics, epidemiology and research design

Improving integrated care and systematically targeting major cancer and non‐cancer causes of morbidity and mortality could yield major benefits

Cancer is the leading cause of death and disability in Australia, and it is estimated that more than 1.6 million people were living with cancer at the end of 2015.1 Most of these people will live with the disease for many years; for all cancers combined, five‐year relative survival in 2012–2016 was about 69%.1 Although cancer is regarded by many people as a single condition, it is highly heterogeneous, with extreme variations in experiences and outcomes according to the type, aggressiveness, treatment, and stage of the cancer, and the age and comorbid conditions of the patient.

National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT

Correspondence: emily.banks@anu.edu.au

Acknowledgements:

Emily Banks is supported by a Principal Research Fellowship from the National Health and Medical Research Council.

Competing interests:

No relevant disclosures.

1. Australian Institute of Health and Welfare. Cancer data in Australia (Cat. vol no. CAN 122). Canberra: AIHW, 2020: https://www.aihw.gov.au/reports/cancer/cancer-data-in-australia (viewed Mar 2021).
2. Koczwara B, Meng R, Miller M, et al. Late mortality in people with cancer: a population‐based Australian study. Med J Aust 2021; 214: 318–323.
3. Zaorsky NG, Churilla TM, Egleston BL, et al. Causes of death among cancer patients. Ann Oncol 2017; 28: 400–407.
4. Australian Institute of Health and Welfare. Australian Burden of Disease Study: impact and causes of illness and death in Australia 2015 (Australian Burden of Disease series no. 19; Cat. no. BOD 22); supplementary table S4.5. Canberra: AIHW, 2019. https://www.aihw.gov.au/getmedia/a67416f3-7713-43f0-b96b-a7ab3c104845/ABDS2015-detailed-report-supplementary-tables-final.xlsx.aspx (viewed Mar 2021).
5. Strongman H, Gadd S, Matthews A, et al. Medium and long‐term risks of specific cardiovascular diseases in survivors of 20 adult cancers: a population‐based cohort study using multiple linked UK electronic health records databases. Lancet 2019; 394: 1041–1054.
6. Baade PD, Fritschi L, Eakin EG. Non‐cancer mortality among people diagnosed with cancer (Australia). Cancer Causes Control 2006; 17: 287–297.
7. Banks E, Crouch SR, Korda RJ, et al. Absolute risk of cardiovascular disease events, and blood pressure‐ and lipid‐lowering therapy in Australia. Med J Aust 2016; 204: 320. https://www.mja.com.au/journal/2016/204/8/absolute-risk-cardiovascular-disease-events-and-blood-pressure-and-lipid
8. Weaver KE, Foraker RE, Alfano CM, et al. Cardiovascular risk factors among long‐term survivors of breast, prostate, colorectal, and gynecologic cancers: a gap in survivorship care? J Cancer Surviv 2013; 7: 253–261.
9. National Center for Chronic Disease Prevention; Health Promotion (US) Office on Smoking and Health. The health consequences of smoking: 50 years of progress. A report of the Surgeon General. Atlanta (GA): US Centers for Disease Control and Prevention, 2014. https://www.ncbi.nlm.nih.gov/books/NBK179276 (viewed Mar 2021).
10. Paul CL, Tzelepis F, Boyes AW, et al. Continued smoking after a cancer diagnosis: a longitudinal study of intentions and attempts to quit. J Cancer Surviv 2019; 13: 687–694.
11. Chiuve SE, McCullough ML, Sacks FM, Rimm EB. Healthy lifestyle factors in the primary prevention of coronary heart disease among men: benefits among users and nonusers of lipid‐lowering and antihypertensive medications. Circulation 2006; 114: 160–167.
12. Chiuve SE, Fung TT, Rexrode KM, et al. Adherence to a low‐risk, healthy lifestyle and risk of sudden cardiac death among women. JAMA 2011; 306: 62–69.
13. National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk. 2012. http://www.cvdcheck.org.au/pdf/Absolute_CVD_Risk_Full_Guidelines.pdf (viewed Mar 2021).
14. Chidwick K, Strongman H, Matthews A, et al. Statin use in cancer survivors versus the general population: cohort study using primary care data from the UK clinical practice research datalink. BMC Cancer 2018; 18: 1018.

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Editorials

Does Australia need more catheterisation laboratories to treat heart attack?

Peter L Thompson

Med J Aust 2021; 214 (7): . || doi: 10.5694/mja2.50994
Published online: 19 April 2021

Topics

Diagnostic techniques and procedures

Cardiovascular diseases

Health services administration

Patients receive similar treatment and have similar outcomes whether their initial hospital has cardiac catheterisation facilities or not

That early reperfusion in a cardiac catheterisation laboratory (“cath lab”) can preserve heart muscle in patients with ST‐elevation myocardial infarction (STEMI) is universally accepted,1 as captured in the “time is muscle” mantra. The reperfusion era for patients with STEMI has delivered better outcomes and reduced the number of deaths.2 Debate about whether to achieve reperfusion by lytic therapy or percutaneous coronary intervention (PCI) has also been settled, with agreement that PCI is preferable when available.3

Heart Research Institute, Sir Charles Gairdner Hospital, Perth, WA

Correspondence: peter.thompson@health.wa.gov.au

Competing interests:

No relevant disclosures.

1. Ibanez B, James S, Agewall S, et al; ESC Scientific Document Group. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST‐segment elevation. Eur Heart J 2018; 39: 119–177.
2. Briffa T, Hickling S, Knuiman M, et al. Long term survival after evidence based treatment of acute myocardial infarction and revascularisation: follow‐up of population based Perth MONICA cohort, 1984–2005. BMJ 2009; 338: b36.
3. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003; 361: 13–20.
4. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non‐st-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 23: e139–e228.
5. Collet JP, Thiele H, Barbato E, et al; ESC Scientific Document Group. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST‐segment elevation. Eur Heart J 2020; ehaa575.
6. Fox KAA, Clayton TC, Damman P, et al; FIR Collaboration. Long‐term outcome of a routine versus selective invasive strategy in patients with non‐ST-segment elevation acute coronary syndrome: a meta‐analysis of individual patient data. J Am Coll Cardiol 2010; 55: 2435–2445.
7. Chew DP, Scott IA, Cullen L, et al; NHFA/CSANZ ACS Guideline 2016 Executive Working Group. National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. Heart Lung Circ 2016; 25: 895–951.
8. Thompson SC, Nedkoff L, Katzenellenbogen J, et al. Challenges in managing acute cardiovascular diseases and follow up care in rural areas: a narrative review. Int J Environ Res Public Health 2019; 16: 5126.
9. Ayad M, Hyun K, D'Souza M, et al. Factors that influence whether patients with acute coronary syndromes undergo cardiac catheterisation. Med J Aust 2021; 214: 310–317.
10. Tideman PA, Tirimacco R, Senior DP, et al. Impact of a regionalised clinical cardiac support network on mortality among rural patients with myocardial infarction. Med J Aust 2014; 200: 157–160. https://www.mja.com.au/journal/2014/200/3/impact-regionalised-clinical-cardiac-support-network-mortality-among-rural

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National Heart Foundation of Australia: position statement on coronary artery calcium scoring for the primary prevention of cardiovascular disease in Australia

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Lessons from the United Kingdom’s COVID‐19 vaccination strategy

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The challenges of managing both chronic pain and opioid use in general practice

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Introducing general practice enrolment in Australia: the devil is in the detail

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Health for all by 2030 is within our grasp: we must act now

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The increasing burden of inflammatory bowel disease

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Evidence‐based care to support longer, healthier lives for cancer survivors

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Artificial intelligence and medical imaging: applications, challenges and solutions

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National Heart Foundation of Australia: position statement on coronary artery calcium scoring for the primary prevention of cardiovascular disease in Australia

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Lessons from the United Kingdom’s COVID‐19 vaccination strategy

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The challenges of managing both chronic pain and opioid use in general practice

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Introducing general practice enrolment in Australia: the devil is in the detail

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Health for all by 2030 is within our grasp: we must act now

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The increasing burden of inflammatory bowel disease

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Lack of efficacy of cannabidiol for relieving back pain: time to re‐set expectations?

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Evidence‐based care to support longer, healthier lives for cancer survivors

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Does Australia need more catheterisation laboratories to treat heart attack?

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Pagination