MJA
MJA

    Presentations to emergency departments by children and young people with food allergy are increasing

    Rachel O'Loughlin and Harriet Hiscock
    Med J Aust 2020; 213 (1): . || doi: 10.5694/mja2.50604
    Published online: 25 May 2020

    The prevalence of food allergy among Victorian children is rising.1 In Victoria, children with suspected food allergies can be on hospital outpatient clinic waiting lists for months before being assessed.2 This may lead families to consider alternative avenues, which can lead to poor allergy management and the need for emergency care. Increasing numbers of Victorian children are presenting to emergency departments,3 but we do not know whether the number visiting with food allergy is also rising.

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      Beyond skin deep: addressing comorbidities in psoriasis

      Tom Kovitwanichkanont, Alvin H Chong and Peter Foley
      Med J Aust 2020; 212 (11): . || doi: 10.5694/mja2.50591
      Published online: 11 May 2020

      Summary

      • Psoriasis is a chronic inflammatory disease that is commonly encountered in primary care and is associated with significant morbidity that extends beyond the skin manifestations.
      • Psoriasis is associated with an elevated risk of psoriatic arthritis, cardiovascular disease, obesity, insulin resistance, mental health disorders, certain types of malignancy, inflammatory bowel disease and other immune‐related disorders, and hepatic and renal disease.
      • Enhanced recognition of these comorbidities may lead to earlier diagnosis and potentially better overall health outcomes.
      • Psoriatic nail involvement, severe skin disease and obesity are associated with a greater risk of psoriatic arthritis. Individuals with psoriasis should be routinely screened for psoriatic arthritis to allow for early intervention to improve long term prognosis.
      • Life expectancy is reduced in people with psoriasis due to a variety of causes, with cardiovascular disease and malignancy being the most common aetiologies.
      • Psoriasis affects several factors that contribute to worsened quality of life and increased risk of depression and anxiety. Effective therapies are now available that have been shown to concurrently improve skin disease, quality of life and psychiatric symptoms.
      • As the concordance between psychosocial impact and objective disease severity does not always correlate, it is essential to tailor management strategies specifically to the needs of each individual.
      • Cigarette smoking and excess alcohol consumption are among the most important modifiable risk factors that increase the likelihood of psoriasis development and severity of skin disease. This provides a compelling rationale for smoking cessation and limiting alcohol intake in people with psoriasis beyond their traditional harmful health consequences.

      • 1 Skin Health Institute, Melbourne, VIC
      • 2 St Vincent's Hospital, Melbourne, VIC


      Competing interests:

      Peter Foley is a consultant, investigator, speaker and/or advisor for, and/or received travel grants from 3M/iNova/Valeant, Abbott/AbbVie, Amgen, Biogen, Bristol Myers Squibb, Boehringer Ingelheim, Celgene, Celtaxsys, Cutanea, Dermira, Eli Lilly, Galderma, GSK/Stiefel, Janssen, LEO Pharma/Peplin, Novartis, Regeneron Pharmaceuticals, Roche, Sanofi Genzyme, Schering‐Plough/MSD, Sun Pharma, UCB and Wyeth/Pfizer.

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        Marked variation in out‐of‐pocket costs for cancer care in Western Australia

        Neli S Slavova‐Azmanova, Jade C Newton and Christobel M Saunders
        Med J Aust 2020; 212 (11): . || doi: 10.5694/mja2.50590
        Published online: 4 May 2020

        Out‐of‐pocket expenses for cancer care are of growing concern for patients, clinicians, service providers, non‐governmental organisations, private insurers, and politicians. Contrary to popular belief, there is no direct link between the cost and quality of care. Out‐of‐pocket expenses are a particular problem for patients who live further from treatment centres, are younger, or have later stage disease.1

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        • The University of Western Australia, Perth, WA


        Acknowledgements: 

        Our investigation was funded by the Cancer Council of Western Australia and the WA Cancer and Palliative Care Network.

        Competing interests:

        No relevant disclosures.

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          A case of toxigenic, pharyngeal diphtheria in Australia

          Sarah Grigg, David Hogan, F Shaun Hosein, Dean Johns, Amy Jennison and Shradha Subedi
          Med J Aust 2020; 213 (2): . || doi: 10.5694/mja2.50566
          Published online: 4 May 2020

          A 42‐year‐old woman presented to the Sunshine Coast University Hospital, Queensland, with a 5‐day history of odynophagia, orthopnoea and rapid onset of neck swelling over 12 hours. She had returned one week prior from a year‐long trip to Central America, Sri Lanka and Indonesia. Relevant past medical history included nephrotic syndrome due to minimal change disease, use of prednisolone 2.5 mg daily and previous treatment with rituximab. Childhood vaccinations were reported, but she had no booster travel vaccinations.


          • 1 Sunshine Coast Hospital and Health Service, Sunshine Coast, QLD
          • 2 Griffith University, Sunshine Coast, QLD
          • 3 Forensic and Scientific Services, Brisbane, QLD


          Correspondence: sarahgrigg28@gmail.com
          Competing interests:

          No relevant disclosures.

          • 1. Nakao H, Pruckler JM, Mazurova IK, et al. Heterogeneity of diphtheria toxin gene, tox, and its regulatory element, dtxR, in Corynebacterium diphtheriae strains causing epidemic diphtheria in Russia and Ukraine. J Clin Microbiol 1996; 34: 1711–1716.
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            The carbon footprint of pathology testing

            Scott McAlister, Alexandra L Barratt, Katy JL Bell and Forbes McGain
            Med J Aust 2020; 212 (8): . || doi: 10.5694/mja2.50583
            Published online: 4 May 2020

            Abstract

            Objectives: To estimate the carbon footprint of five common hospital pathology tests: full blood examination; urea and electrolyte levels; coagulation profile; C‐reactive protein concentration; and arterial blood gases.

            Design, setting: Prospective life cycle assessment of five pathology tests in two university‐affiliated health services in Melbourne. We included all consumables and associated waste for venepuncture and laboratory analyses, and electricity and water use for laboratory analyses.

            Main outcome measure: Greenhouse gas footprint, measured in carbon dioxide equivalent (CO2e) emissions.

            Results: CO2e emissions for haematology tests were 82 g/test (95% CI, 73–91 g/test) for coagulation profile and 116 g/test (95% CI, 101–135 g/test) for full blood examination. CO2e emissions for biochemical tests were 0.5 g/test CO2e (95% CI, 0.4–0.6 g/test) for C‐reactive protein (low because typically ordered with urea and electrolyte assessment), 49 g/test (95% CI, 45–53 g/test) for arterial blood gas assessment, and 99 g/test (95% CI, 84–113 g/test) for urea and electrolyte assessment. Most CO2e emissions were associated with sample collection (range, 60% for full blood examination to 95% for coagulation profile); emissions attributable to laboratory reagents and power use were much smaller.

            Conclusion: The carbon footprint of common pathology tests was dominated by those of sample collection and phlebotomy. Although the carbon footprints were small, millions of tests are performed each year in Australia, and reducing unnecessary testing will be the most effective approach to reducing the carbon footprint of pathology. Together with the detrimental health and economic effects of unnecessary testing, our environmental findings should further motivate clinicians to test wisely.

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            • 1 The University of Melbourne, Melbourne, VIC
            • 2 Sydney School of Public Health, University of Sydney, Sydney, NSW
            • 3 Western Health, Melbourne, VIC


            Acknowledgements: 

            Funding for this investigation (data collection, life cycle assessment analysis, report writing) was provided by the Victorian Department of Health and Human Services, Choosing Wisely Australia, and by a National Health and Medical Research Council Centre for Research Excellence grant (Alexandra Barratt: 1104136). Scott McAlister is supported by a National Health and Medical Research Council PhD scholarship. Cathy Cockshott provided access to the Sunshine Hospital pathology laboratory, and Nick Crinis to the Austin Hospital pathology laboratory, to allow collection of data about analysers and reagents.

            Competing interests:

            No relevant disclosures.

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              Telemedicine is improving outcomes for patients with stroke

              Richard I Lindley
              Med J Aust 2020; 212 (8): . || doi: 10.5694/mja2.50587
              Published online: 4 May 2020

              Technology is revolutionising medicine, and telemedicine is having a measurable impact on stroke care

              Technology is revolutionising medicine, and telemedicine for patients with stroke (telestroke) is now having a measurable impact on outcomes. Acute stroke care is challenging for many reasons: stroke mimics are common (about 30% of all cases initially suspected to be stroke);1 patients with intracerebral haemorrhage and ischaemic stroke can present with identical syndromes, making brain imaging essential for diagnosis; treatments must be initiated without delay, and some require transfer for tertiary intervention (eg, endovascular thrombectomy). The lack of specialist stroke physicians in regional Australia and underinvestment in stroke care results in poor access for many Australians. Unwarranted clinical variation is unacceptable, so why do some regions of Australia, even today, have no access to specialist stroke care? The answers are complex, but some are clear (too few specialists in regional areas), while some are more difficult to understand (health providers declining offers of help).


              • 1 Westmead Applied Research Centre, University of Sydney, Sydney, NSW
              • 2 The George Institute for Global Health, Sydney, NSW


              Acknowledgements: 

              I am supported by a National Health and Medical Research Council program grant (APP1149987: Clinical, public health and policy interventions to combat cardiovascular diseases).

              Competing interests:

              No relevant disclosures.

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              • 12. Reed SD, Cramer SC, Blough DK, et al. Treatment with tissue plasminogen activator and inpatient mortality rates for patients with ischemic stroke treated in community hospitals. Stroke 2001; 32: 1832–1840.
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                Hepatitis C elimination in Australia: progress and challenges

                Marianne Martinello, Behzad Hajarizadeh and Gregory J Dore
                Med J Aust 2020; 212 (8): . || doi: 10.5694/mja2.50584
                Published online: 4 May 2020

                Early empirical evidence provides grounds for optimism about eliminating HCV by 2030

                Curative direct‐acting antiviral (DAA) therapy for people with chronic hepatitis C virus (HCV) infections1 has transformed clinical management and spurred ambitious World Health Organization elimination targets for 2030.2 WHO service targets encompass marked improvements in prevention, diagnosis, and treatment; impact targets include a 65% reduction in HCV‐related deaths and an 80% reduction in new HCV infections compared with 2015.2


                • Kirby Institute, UNSW, Sydney, NSW


                Competing interests:

                Gregory Dore is an advisory board member and has received honoraria, research grant funding, and travel sponsorship from Merck, Gilead, and Abbvie.

                • 1. Spearman CW, Dusheiko GM, Hellard M, Sonderup M. Hepatitis C. Lancet 2019; 394: 1451–1466.
                • 2. Word Health Organization. Global health sector strategy on viral hepatitis, 2016–2021 (WHO/HIV/2016.06). Geneva: WHO, 2016. https://www.who.int/hepatitis/strategy2016-2021/ghss-hep/en/ (viewed Mar 2020).
                • 3. Hajarizadeh B, Grebely J, Matthews GV, et al. Uptake of direct‐acting antiviral treatment for chronic hepatitis C in Australia. J Viral Hepat 2018; 25: 640–648.
                • 4. Iversen J, Dore GJ, Catlett B, et al. Association between rapid utilisation of direct hepatitis C antivirals and decline in the prevalence of viremia among people who inject drugs in Australia. J Hepatol 2019; 70: 33–39.
                • 5. Iranpour N DG, Martinello M, Matthews G, et al. Estimated uptake of hepatitis C direct‐acting antiviral treatment among individuals with HIV co‐infection in Australia: a retrospective cohort study. Sexual Health 2020; https://doi.org/10.1071/sh19101 [Epub ahead of print].
                • 6. Moon S, Erickson E. Universal medicine access through lump‐sum remuneration: Australia's approach to hepatitis C. N Engl J Med 2019; 380: 607–610.
                • 7. Alavi M, Law MG, Valerio H, et al. Declining hepatitis C virus‐related liver disease burden in the direct‐acting antiviral therapy era in New South Wales, Australia. J Hepatol 2019; 71: 281–288.
                • 8. Scott N, Sacks‐Davis R, Wade AJ, et al. Australia needs to increase testing to achieve hepatitis C elimination. Med J Aust 2020; 212: 365–370.
                • 9. NSW Government. NSW hepatitis B and hepatitis C strategies 2014–2020 data report: 2018 annual data report. 2018. https://www.health.nsw.gov.au/hepatitis/Publications/2018-annual-data-report.pdf (viewed Mar 2020).
                • 10. Larney S, Peacock A, Leung J, et al. Global, regional, and country‐level coverage of interventions to prevent and manage HIV and hepatitis C among people who inject drugs: a systematic review. Lancet Glob Health 2017; 5: e1208–e1220.
                • 11. Fraser H, Zibbell J, Hoerger T, et al. Scaling‐up HCV prevention and treatment interventions in rural United States‐ model projections for tackling an increasing epidemic. Addiction 2017; 113: 173–182.
                • 12. The Kirby Institute. Monitoring hepatitis C treatment uptake in Australia (issue 10). June 2019. https://kirby.unsw.edu.au/report/monitoring-hepatitis-c-treatment-uptake-australia-issue-10-june-2019 (viewed Mar 2020).
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                  Environmentally sustainable health care: now is the time for action

                  Diana L Madden, Anthony Capon and Philip G Truskett
                  Med J Aust 2020; 212 (8): . || doi: 10.5694/mja2.50586
                  Published online: 4 May 2020

                  Excellence in environmentally sustainable health care must be the goal of the Australian medical profession

                  The bushfires that recently raged across south‐eastern Australia have again shown that climate change has serious health consequences. Thirty‐four people died, and half the Australian population was exposed to sustained, hazardous levels of air pollution.1 Mental health experts are flagging rising levels of eco‐anxiety about bushfires and climate change in general.2 The intensity and scale of the bushfires, which were amplified by climate change, have highlighted the urgent need for climate action.3 It is timely for clinicians and health care managers to reflect on the environmental footprint — including the carbon footprint — of the health care we provide, and to act to reduce it.


                  • 1 University of Notre Dame Australia, Sydney, NSW
                  • 2 Monash Sustainable Development Institute, Monash University, Melbourne, VIC
                  • 3 University of New South Wales, Sydney, NSW
                  • 4 Royal Australasian College of Surgeons, Melbourne, VIC


                  Correspondence: lynne.madden@nd.edu.au
                  Competing interests:

                  No relevant disclosures.

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                    A sustainable future in health: ensuring as health professionals our own house is in order and leading by example

                    Nicholas J Talley
                    Med J Aust 2020; 212 (8): . || doi: 10.5694/mja2.50574
                    Published online: 4 May 2020

                    It is time for health professionals to step up and lead to ensure a sustainable environment and health

                    The year 2020 is fast becoming the year of planetary crises, from global warming and the unprecedented bushfire season in Australia over the summer to the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) pandemic striking around the globe, with its health and financial implications.1,2,3 Social media is littered with often uninformed opinions about both issues, from those unconcerned and arguing the problems are exaggerated or worse to those who are deeply concerned and searching for better solutions. The facts about the climate crisis and health are more stark, as pointed out by Madden and Capon4 in this issue of the Journal and by the most recent Lancet–MJA countdown report5 — overwhelming evidence points to a warming planet because of human activity and to the potential for very severe adverse health consequences, including other infectious disease outbreaks, if prompt action is not taken now. The recent unprecedented bushfire season may have shifted views about the potential for severe impacts of global warming on health, just as the unfolding health crisis with COVID‐19 has highlighted how vulnerable our health systems are to new pathogens. There has not been political inertia in the United Kingdom, where all sides of politics recognise the global emergency we all face because of climate change.6 However, more effective political action is needed here and around the world in terms of ensuring a sustainable future.

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                    • University of Newcastle, Newcastle, NSW


                    Competing interests:

                    Nicholas Talley is Editor‐in‐Chief of the Medical Journal of Australia. A complete list of disclosures is available at https://www.mja.com.au/journal/staff/editor-chief-professor-nick-talley.

                    • 1. Yu P, Xu R, Abramson MJ, et al. Bushfires in Australia: a serious health emergency under climate change. Lancet Planet Health 2020; 4: e7–e8.
                    • 2. Vardoulakis S, Jalaludin BB, Morgan GG, et al. Bushfire smoke: urgent need for a national health protection strategy. Med J Aust 2020; 212: 349–353.
                    • 3. Cheng A, Williamson D. An outbreak of COVID‐19 caused by a new coronavirus: what we know so far. Med J Aust 2020; https://doi.org/10.5694/mja2.50530 [Epub ahead of print]. https://www.mja.com.au/journal/2020/212/10/outbreak-covid-19-caused-new-coronavirus-what-we-know-so-far
                    • 4. Madden DL, Capon A, Truskett PG. Environmentally sustainable health care: now is the time for action. Med J Aust 2020; 212: 361–362.
                    • 5. Beggs PJ, Zhang Y, Bambrick H, et al. The 2019 report of the MJA–Lancet Countdown on health and climate change: a turbulent year with mixed progress. Med J Aust 211: 490–491. https://www.mja.com.au/journal/2019/211/11/2019-report-mja-lancet-countdown-health-and-climate-change-turbulent-year-mixed
                    • 6. BBC News. UK Parliament declares climate emergency. BBC News 2019, 1 May. https://www.bbc.com/news/uk-politics-48126677 (viewed Mar 2020).
                    • 7. Malik A, Lenzen M, McAlister S, McGain F. The carbon footprint of Australian health care. Lancet Planet Health 2018; 2: e27–35.
                    • 8. Sainsbury P, Charlesworth K, Madden D, et al. Climate change is a health issue: what can doctors do? Intern Med J 2019; 49: 1044–1048.
                    • 9. Sutton B, Mulvenna V, Voronoff D, Humphrys T. Acting on climate change and health in Victoria. Med J Aust 2020; 212: 345–346.
                    • 10. Weeramanthri TS, Joyce S, Bangor‐Jones R. Climate health inquiry: where sustainability, public health law and climate action intersect. Med J Aust 2020; 212: 347–349.
                    • 11. NHS England, Public Health England. Sustainable Development Unit: what is sustainable health? [website] https://www.sduhealth.org.uk/policy-strategy/what-is-sustainable-health.aspx (viewed Mar 2020).
                    • 12. Ripple WJ, Wolf C, Newsome TM, et al. World scientists’ warning of a climate emergency. BioScience 2020; 70: 8–12.
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                      General practice research: an investment to improve the health of all Australians

                      Jo‐Anne E Manski‐Nankervis, Elizabeth A Sturgiss, Siaw‐Teng Liaw, Geoffrey K Spurling and Danielle Mazza
                      Med J Aust 2020; 212 (9): . || doi: 10.5694/mja2.50589
                      Published online: 27 April 2020

                      Opportunities to recognise and invest in general practice research need to be realised

                      General practice research is essential to quality general practice, building an evidence base for over 27 000 general practitioners working within the specialty who provide medical care to the majority of Australians.1 Over eight in ten Australians consult with their GP at least once per year, and two million people are seen each week in general practice.2,3 General practice, a medical specialty, is the first point of access to the health system, providing longitudinal care for all. It is essential for the delivery of efficient, equitable and effective health care services.4 General practice is unique, complex and continuing to evolve. A GP must have a good working knowledge of 167 problems to cover 85% of the conditions that they see most frequently,5 and management of multimorbidity has become the norm. The number of general practices appears to be declining, practices are becoming larger, and the proportion of GPs who are practice owners is decreasing.6 General practice research is key to optimising health care in this evolving context, but needs to be supported by the profession, funders and our professional colleges.


                      • 1 University of Melbourne, Melbourne, VIC
                      • 2 Monash University, Melbourne, VIC
                      • 3 UNSW Sydney, Sydney, NSW
                      • 4 Ingham Institute of Applied Medical Research, Sydney, NSW
                      • 5 University of Queensland, Brisbane, QLD


                      Correspondence: jomn@unimelb.edu.au
                      Competing interests:

                      All authors are members of the Australasian Association for Academic Primary Care (AAAPC) and the RACGP Expert Committee – Research, for which they receive sitting fees. Jo‐Anne Manski‐Nankervis is supported by an MRFF Next Generation Clinical Researcher TRIP Fellowship and receives research funding from the RACGP Foundation. Elizabeth Sturgiss is supported by a National Health and Medical Research Council (NHMRC) Investigator Grant (EL1) and is Conference Subcommittee Chair for the AAAPC. Siaw‐Teng Liaw receives sitting fees as Chair of the RACGP National Research and Evaluation Ethics Committee and has received research funding from the Australian Research Council (ARC), the NHMRC, the Ramaciotti Foundations and the HCF Research Foundation. Geoffrey Spurling is supported by an NHMRC Investigator Grant (EL1) and has received funding from the ARC and RACGP Foundation. Danielle Mazza has received research funding, speaker fees and travel support to attend conferences from Bayer and MSD.

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