Topics

An 80‐year‐old man presented with 2 days of fever and a widespread, itchy, non‐blanching, erythematous rash involving more than 50% of body surface area over arms, legs, abdomen, back and palms, with sparing of the face and soles of feet (Box 1). He had a history of type 2 diabetes mellitus (treated with sitaglipin 100 mg and metformin 1000 mg modified release daily), hypertension (perindopril arginine 2.5 mg daily), vitamin D deficiency (weekly colecalciferol 125 μg oral) and pernicious anaemia.

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

Correspondence: g.martin@alfred.org.au

Acknowledgements:

We acknowledge the input of Jason Trubiano and Nigel Crawford for valuable discussions in the management of this case.

Competing interests:

No relevant disclosures.

1. Kardaun SH, Sidoroff A, Valeyrie‐Allanore L, et al. Variability in the clinical pattern of cutaneous side‐effects of drugs with systemic symptoms: does a DRESS syndrome really exist? Br J Dermatol 2007; 156: 609–611.
2. O'Hagan DT, Ott GS, De Gregorio E, Seubert A. The mechanism of action of MF59 — an innately attractive adjuvant formulation. Vaccine 2012; 30: 4341–4348.
3. Schaffner W, Chen WH, Hopkins RH, Neuzil K. Effective immunization of older adults against seasonal influenza. Am J Med 2018; 131: 865–873.
4. Solak B, Dikicier BS, Kara RO, Erdem T. DRESS syndrome potentially induced by allopurinol and triggered by influenza vaccine. BMJ Case Rep 2016; 2016: bcr2016214563.
5. Hewitt N, Levinson M, Stephenson G. Drug reaction with eosinophilia and systemic symptoms associated with H1N1 vaccination. Intern Med J 2012; 42: 1365–1366.
6. Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981; 30: 239–245.
7. Shiohara T. The role of viral infection in the development of severe drug eruptions. Dermatologica Sinica 2013; 31: 205–210.
8. Ramírez E, Medrano‐Casique N, Tong HY, et al. Eosinophilic drug reactions detected by a prospective pharmacovigilance programme in a tertiary hospital. Br J Clin Pharmacol 2017; 83: 400–415.
9. Villa M, Black S, Groth N, et al. Safety of MF59‐adjuvanted influenza vaccination in the elderly: results of a comparative study of MF59‐adjuvanted vaccine versus nonadjuvanted influenza vaccine in northern Italy. Am J Epidemiol 2013; 178: 1139–1145.
10. Lindert K, Leav B, Heijnen E, et al. Cumulative clinical experience with MF59‐adjuvanted trivalent seasonal influenza vaccine in young children and adults 65 years of age and older. Int J Infect Dis 2019; 85S: S10–S17.

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Perspectives

Sodium–glucose cotransporter type 2 inhibitors: managing the small but critical risk of diabetic ketoacidosis

Peter S Hamblin, Rosemary Wong and Leon A Bach

Med J Aust 2020; 212 (7): . || doi: 10.5694/mja2.50525
Published online: 20 April 2020

Topics

Endocrine system diseases

Pharmaceutical preparations

Risk of SGLT2 inhibitor‐associated diabetic ketoacidosis in type 2 diabetes: some answers, but more questions

Prescribers have enthusiastically embraced sodium–glucose cotransporter type 2 (SGLT2) inhibitors for the treatment of type 2 diabetes on the strength of accumulating data reporting improved cardiovascular and renal outcomes. In Australia, in 2016, 757 826 Pharmaceutical Benefits Scheme and Repatriation Pharmaceutical Benefits Scheme prescriptions containing an SGLT2 inhibitor were dispensed. By 2019, that number had risen to 2.3 million.1 Assuming these scripts are dispensed monthly, an estimated 19% of all patients with type 2 diabetes (about 190 000 people) are currently being treated with SGLT2 inhibitors.

1 Western Health, Melbourne, VIC
2 University of Melbourne, Melbourne, VIC
3 Box Hill Hospital, Melbourne, VIC
4 Alfred Health, Melbourne, VIC
5 Monash University, Melbourne, VIC

Correspondence: peter.hamblin@wh.org.au

Competing interests:

Leon Bach was an investigator in the DECLARE study.

1. Australian Government, Department of Human Services. Medicare Australia statistics: Pharmaceutical Benefits Schedule item reports. http://medicarestatistics.humanservices.gov.au/statistics/pbs_item.jsp (viewed Feb 2020).
2. Zinman B, Wanner C, Lachin JM, et al. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med 2015; 373: 2117–2128.
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4. Neal B, Perkovic V, Mahaffey KW, et al. Canagliflozin and cardiovascular and renal events in type 2 diabetes. N Engl J Med 2017; 377: 644–657.
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6. Perkovic V, Jardine MJ, Neal B, et al. Canagliflozin and renal outcomes in type 2 diabetes and nephropathy. N Engl J Med 2019; 380: 2295–2306.
7. Wanner C, Inzucchi SE, Lachin JM, et al. Empagliflozin and progression of kidney disease in type 2 diabetes. N Engl J Med 2016; 375: 323–334.
8. Mosenzon O, Wiviott SD, Cahn A, et al. Effects of dapagliflozin on development and progression of kidney disease in patients with type 2 diabetes: an analysis from the DECLARE–TIMI 58 randomised trial. Lancet Diabetes Endocrinol 2019; 7: 606–617.
9. Hamblin PS, Wong R, Ekinci EI, et al. SGLT2 inhibitors increase the risk of diabetic ketoacidosis developing in the community and during hospital admission. J Clin Endocrinol. Metab 2019; 104: 3077–3087.
10. Cotter DG, Schugar RC, Crawford PA. Ketone body metabolism and cardiovascular disease. Am J Physiol Heart Circ Physiol 2013; 15; 304: H1060–H1076.
11. Australian and New Zealand College of Anaesthetists. Severe euglycaemic ketoacidosis with SGLT2 inhibitor use in the perioperative period [alert]. Melbourne: ANZCA. http://www.anzca.edu.au/documents/alert-dka-and-oral-hypoglycaemics-20180215.pdf (viewed June 2019).
12. Australian Diabetes Society. Alert update January 2020: periprocedural diabetic ketoacidosis (DKA) with SGLT2 inhibitor use. https://diabetessociety.com.au/documents/ADS_DKA_SGLT2i_Alert_update_2020.pdf (viewed Feb 2020).
13. Therapeutic Goods Administration. Adverse Event Management System [accessed 4 June 2019]. Canberra: Australian Government Department of Health, 2019.
14. Daniele G, Xiong J, Solis‐Herrera C, et al. Dapagliflozin enhances fat oxidation and ketone production in patients with type 2 diabetes. Diabetes Care 2016; 39: 2036–2041.
15. Al Jobori H, Daniele G, Adams J, et al. Determinants of the increase in ketone concentrations during SGLT2 inhibition in NGT, IFG and T2DM patients. Diabetes Obes Metab 2017; 19: 809–813.
16. Ferrannini E, Baldi S, Frascerra S, et al. Shift to fatty substrate utilization in response to sodium‐glucose cotransporter 2 inhibition in subjects without diabetes and patients with type 2 diabetes. Diabetes 2016; 65: 1190–1195.
17. Hillier S, Grimmer‐Somers K, Merlin T, et al. FORM: an Australian method for formulating and grading recommendations in evidence‐based clinical guidelines. BMC Med Res Methodol 2011; 11: 23.

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Research

Corticosteroid treatment of patients with coronavirus disease 2019 (COVID‐19)

Lei Zha, Shirong Li, Lingling Pan, Boris Tefsen, Yeshan Li, Neil French, Liyun Chen, Gang Yang and Elmer V Villanueva

Med J Aust 2020; 212 (9): . || doi: 10.5694/mja2.50577
Published online: 13 April 2020

Topics

Infectious diseases

Respiratory tract diseases

Abstract

Objectives: To assess the efficacy of corticosteroid treatment of patients with coronavirus disease 2019 (COVID‐19).

Design, setting: Observational study in the two COVID‐19‐designated hospitals in Wuhu, Anhui province, China, 24 January – 24 February 2020.

Participants: Thirty‐one patients infected with the severe acute respiratory coronavirus 2 (SARS‐CoV‐2) treated at the two designated hospitals.

Main outcome measures: Virus clearance time, length of hospital stay, and duration of symptoms, by treatment type (including or not including corticosteroid therapy).

Results: Eleven of 31 patients with COVID‐19 received corticosteroid treatment. Cox proportional hazards regression analysis indicated no association between corticosteroid treatment and virus clearance time (hazard ratio [HR], 1.26; 95% CI, 0.58–2.74), hospital length of stay (HR, 0.77; 95% CI, 0.33–1.78), or duration of symptoms (HR, 0.86; 95% CI, 0.40–1.83). Univariate analysis indicated that virus clearance was slower in two patients with chronic hepatitis B infections (mean difference, 10.6 days; 95% CI, 6.2–15.1 days).

Conclusions: Corticosteroids are widely used when treating patients with COVID‐19, but we found no association between therapy and outcomes in patients without acute respiratory distress syndrome. An existing HBV infection may delay SARS‐CoV‐2 clearance, and this association should be further investigated.

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1 Xi'an Jiaotong–Liverpool University, Suzhou, Jiangsu, China
2 The Second People's Hospital of Wuhu, Wuhu, Anhui, China
3 Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
4 Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
5 The Third People's Hospital of Wuhu, Wuhu, Anhui, China

Correspondence: Villanueva@xjtlu.edu.cn

Acknowledgements:

We thank everyone fighting the epidemic of COVID‐19 around the world.

Competing interests:

No relevant disclosures.

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16. Hui DS. Systemic corticosteroid therapy may delay viral clearance in patients with Middle East respiratory syndrome coronavirus infection. Am J Respir Crit Care Med 2018; 197: 700–701.
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19. Zhao JP, Hu Y, Du RJ, et al. Expert consensus on the use of corticosteroid in patients with 2019‐nCoV pneumonia] [Chinese]. Zhonghua Jie He He Hu Xi Za Zhi [Chinese Journal of Tuberculosis and Respiratory Medicine] 2020; 43: E007.
20. Mo Y, Fisher D. A review of treatment modalities for Middle East respiratory syndrome. J Antimicrob Chemother 2016; 71: 3340–3350.
21. Haviernik J, Štefánik M, Fojtíková M, et al. Arbidol (Umifenovir): a broad‐spectrum antiviral drug that inhibits medically important arthropod‐borne flaviviruses. Viruses 2018; 10: E184.
22. Xu XW, Wu XX, Jiang XG, et al. Clinical findings in a group of patients infected with the 2019 novel coronavirus (SARS‐Cov‐2) outside of Wuhan, China: retrospective case series. BMJ 2020 Feb 19; 19(368): m606.
23. Xu Z, Shi L, Wang Y, et al. Pathological findings of COVID‐19 associated with acute respiratory distress syndrome. Lancet Respir Med 2020; https://doi.org/10.1016/s2213-2600(20)30076-x [Epub ahead of print].
24. Quispe‐Laime AM, Bracco JD, Barberio PA, et al. H1N1 influenza A virus‐associated acute lung injury: response to combination oseltamivir and prolonged corticosteroid treatment. Intensive Care Med 2010; 36: 33–41.
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28. Chen J, Xi XH, Liu P, et al. [Efficacies of lopinavir/ritonavir and abidol in the treatment of novel coronavirus pneumonia] [Chinese]. Zhōnghuá chuánrǎn bìng zázhì [Chinese Journal of Infectious Diseases] 2020; https://doi.org/10.3760/cma.j.cn311365-20200210-00050 [Epub ahead of print].

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Perspectives

One disease, two vaccines: challenges in prevention of meningococcal disease

Cyra Patel, Clayton K Chiu, Frank H Beard, Nigel W Crawford and Kristine Macartney

Med J Aust 2020; 212 (10): . || doi: 10.5694/mja2.50567
Published online: 13 April 2020

Correction(s) for this article:

Erratum | Published online: 7 April 2025

Topics

Infectious diseases

Environment and public health

Gaps in availability of both meningococcal ACWY and B vaccines exist for high risk groups

1 National Centre for Immunisation Research and Surveillance, Sydney Children's Hospital Network, Sydney, NSW
2 University of Sydney, Sydney, NSW
3 Murdoch Children's Research Institute, Melbourne, VIC
4 University of Melbourne, Melbourne, VIC

Correspondence: frank.beard@health.nsw.gov.au

Acknowledgements:

We thank Katrina Clark for her review and input into the article. The authors received no financial support specifically for the authorship and/or publication of this article. The views expressed in this article are those of the individual authors, and are not necessarily the views of the Australian Technical Advisory Group on Immunisation (ATAGI), the Department of Health, or the National Immunisation Program. For information from the ATAGI, please see the meningococcal chapter in the Australian immunisation handbook.

Competing interests:

Cyra Patel, Clayton Chiu, Frank Beard and Kristine Macartney are employed at the National Centre for Immunisation Research and Surveillance, which receives funding from the Australian Government Department of Health for contracted work to support ATAGI. No specific funding was provided for the drafting or publication of this manuscript.

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2. Lawrence GL, Wang H, Lahra M, et al. Meningococcal disease epidemiology in Australia 10 years after implementation of a national conjugate meningococcal C immunization programme. Epidemiol Infect 2016; 144: 2382–2391.
3. Archer BN, Chiu CK, Jayasinghe SH, et al. Epidemiology of invasive meningococcal B disease in Australia, 1999–2015: priority populations for vaccination. Med J Aust 2017; 207: 382–387. https://www.mja.com.au/journal/2017/207/9/epidemiology-invasive-meningococcal-b-disease-australia-1999-2015-priority
4. Australian Government, Department of Health. Invasive meningococcal disease national surveillance quarterly report; quarter 4, 2018. https://www.health.gov.au/internet/main/publishing.nsf/Content/5FEABC4B495BDEC1CA25807D001327FA/$File/1Oct-31Dec19-qrt3-IMD.pdf (viewed June 2019).
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6. Australian Technical Advisory Group on Immunisation. The Australian immunisation handbook: meningococcal disease. Canberra: Australian Government, Department of Health, 2018. https://immunisationhandbook.health.gov.au/vaccine-preventable-diseases/meningococcal-disease (viewed Jan 2020).
7. Figueroa J, Densen P. Infectious diseases associated with complement deficiencies. Clin Microbiol Rev 1991; 4: 359–395.
8. National Centre for Immunisation Research and Surveillance. Significant events in meningococcal vaccination practice in Australia, 2019. http://ncirs.org.au/sites/default/files/2019-12/Meningococcal-history-Dec%202019.pdf (viewed Jan 2020).
9. Marshall H, McMillan M, Koehler A, et al. Meningococcal B vaccine and meningococcal carriage in adolescents in Australia. N Engl J Med 2020; 382: 318–327.
10. Christensen H, May M, Bowen L, et al. Meningococcal carriage by age: a systematic review and meta‐analysis. Lancet Infect Dis 2010; 10: 853–861.
11. Northern Territory Government, Department of Health. Update — meningococcal outbreak in Central Australia, 2017. http://mediareleases.nt.gov.au/mediaRelease/23779 (viewed July 2019).
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13. Nolan T, Santolaya ME, de Looze F, et al. Antibody persistence and booster response in adolescents and young adults 4 and 7.5 years after immunization with 4CMenB vaccine. Vaccine 2019; 37: 1209–1218.
14. Ladhani S, Andrews N, Parikh S, et al. Vaccination of infants with meningococcal group B vaccine (4CMenB) in England. N Engl J Med 2020; 382: 309–317.
15. Medini D, Stella M, Wassil J. MATS: global coverage estimates for 4CMenB, a novel multicomponent meningococcal B vaccine. Vaccine 2015; 33: 2629–2636.
16. Nolan TM. The Australian model of immunization advice and vaccine funding. Vaccine 2010; 28: A76–A83.
17. Trotter C, Maiden MC. Meningococcal vaccines and herd immunity: lessons learned from serogroup C conjugate vaccination programs. Expert Rev Vaccines 2009; 8: 851–861.
18. Pharmaceutical Benefits Advisory Committee. May 2019 PBAC meeting — positive recommendations. http://www.pbs.gov.au/industry/listing/elements/pbac-meetings/pbac-outcomes/2019-05/positive-recommendations-05-2019.pdf (viewed June 2019).
19. Pharmaceutical Benefits Advisory Committee. Public summary document — 5.06 meningococcal polysaccharide conjugate vaccine serogroups A, C, W‐135 and Y, pre‐filled syringe, 0.5 mL, Nimenrix, Pfizer Australia Pty Ltd. 2018. http://www.pbs.gov.au/industry/listing/elements/pbac-meetings/psd/2018-03/files/men-acwy-vaccine-infants-psd-march-2018.pdf (viewed July 2019).
20. Pharmaceutical Benefits Advisory Committee. November 2019 PBAC meeting — positive recommendations. http://www.pbs.gov.au/industry/listing/elements/pbac-meetings/pbac-outcomes/2019-11/positive-recommendations-11-2019.docx.pdf (viewed Jan 2020).
21. Beard FH, Clark KK. High rates of vaccination of Aboriginal and Torres Strait Islander Australians: an underappreciated success? Med J Aust 2019; 211: 17–18. https://www.mja.com.au/journal/2019/211/1/high-rates-vaccination-aboriginal-and-torres-strait-islander-australians

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Research letter

Decline in new medical graduates registered as general practitioners

Denese Playford, Jennifer A May, Hanh Ngo and Ian B Puddey

Med J Aust 2020; 212 (9): . || doi: 10.5694/mja2.50563
Published online: 13 April 2020

Topics

General medicine

Health occupations

Health services administration

Primary care is the single most significant contributor to positive health outcomes,1,2 but the number of general practitioners in Australia has been falling, a situation previously described for nations with poorer health outcomes.2 The reasons for the decline are many,3 but this phenomenon has not been described in detail in the peer‐reviewed literature. We have therefore examined the registration categories, as recorded by the Australian Health Practitioner Regulation Agency (AHPRA), of people who graduated from the University of Western Australia (UWA) medical school during 1985–2007. Our study was approved by the UWA Human Research Ethics Committee (reference, RA 4/1/1627).

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1 The Rural Clinical School of WA, University of Western Australia, Perth, WA
2 University of Newcastle, Tamworth, NSW
3 The University of Western Australia, Perth, WA

Correspondence: denese.playford@uwa.edu.au

Competing interests:

No relevant disclosures.

1. Starfield B, Horder J. Interpersonal continuity: old and new perspectives. Br J Gen Pract 2007; 57: 527–529.
2. Basu S, Berkowitz SA, Phillips RL, et al. Association of primary care physician supply with population mortality in the United States, 2005–2015. JAMA Intern Med 2018; 179: 506–514.
3. Ianuzzi A. General practice: where the problems lie. MJA Insight [online], 25 June 2018. https://insightplus.mja.com.au/2018/2024/general-practice-where-the-problems-lie (viewed Mar 2020).
4. Medical Board of Australia. General registration. Updated Aug 2018. https://www.medicalboard.gov.au/Registration/Types/General-Registration.aspx (viewed Jan 2020).
5. Medical Deans Australia and New Zealand. Medical Schools Outcomes Database: national data report 2019. Data from final year students at Australian medical schools. Sept 2019. https://medicaldeans.org.au/md/2019/09/2019-MSOD-National-Data-Report-2014-2018-Full-report.pdf (viewed Jan 2020).
6. McNamara S. Does it take too long to become a doctor? Part 1: Medical school and prevocational training. Med J Aust 2012; 196: 528–530. https://www.mja.com.au/journal/2012/196/8/does-it-take-too-long-become-doctor.

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Research

A new model of care and in‐house general practitioners for residential aged care facilities: a stepped wedge, cluster randomised trial

Terry P Haines, Andrew J Palmer, Petra Tierney, Lei Si and Andrew L Robinson

Med J Aust 2020; 212 (9): . || doi: 10.5694/mja2.50565
Published online: 6 April 2020

Topics

Gerontology

Abstract

Objectives: To evaluate whether an alternative model of care in aged care facilities, including in‐house general practitioners, influenced health outcomes for residents.

Design: Stepped wedge, cluster randomised controlled trial over 90 weeks (31 December 2012 – 21 September 2014), with a 54‐week pre‐trial retrospective data period (start: 19 December 2011) and a 54‐week post‐trial prospective data collection period (to 4 October 2015).

Participants, setting: Fifteen residential aged care facilities operated by Bupa Aged Care in metropolitan and regional cities in four Australian states.

Intervention: Residential aged care facilities sought to recruit general practitioners as staff members; care staff roles were redefined to allow registered nurses greater involvement in care plan development.

Main (primary) outcome measures: Numbers of falls; numbers of unplanned transfers to hospital; polypharmacy.

Results: The new model of care could be implemented in all facilities, but four could not recruit in‐house GPs at any time during the trial period. Intention‐to‐treat analyses found no statistically significant effect of the intervention on the primary outcome measures. Contamination‐adjusted intention‐to‐treat analyses identified that the presence of an in‐house GP was associated with reductions in the numbers of unplanned hospital transfers (incidence rate ratio [IRR], 0.53; 95% CI, 0.43–0.66) and admissions (IRR, 0.52; 95% CI, 0.41–0.64) and of out‐of‐hours GP call‐outs (IRR, 0.54; 95% CI, 0.36–0.80), but also with an increase in the number of reported falls (IRR, 1.37; 95% CI, 1.20–1.58).

Conclusions: Recruiting GPs to work directly in residential aged care facilities is difficult, but may reduce the burden of unplanned presentations to hospitals and increase the reporting of adverse events.

Trial registration: Australia New Zealand Clinical Trial Registry, ACTRN12613000218796 (25 February 2013).

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1 Monash University, Melbourne, VIC
2 Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS
3 Wicking Dementia Research and Education Centre, University of Tasmania, Hobart, TAS
4 Bupa Aged Care Australia, Sydney, NSW

Correspondence: terrence.haines@monash.edu

Acknowledgements:

Terry Haines was supported by a National Health and Medical Research Council Career Development Fellowship.

Competing interests:

This study was funded by the Bupa Health Foundation, and the trial was conducted at Bupa Aged Care facilities. The Bupa Health Foundation had no role in the study design, data collection, analysis or interpretation, reporting or publication. There were no financial relationships with any organisations with an interest in the research question during the preceding three years. Petra Tierney was employed by Bupa Aged Care during the trial but not during manuscript preparation. A copy of the project report was submitted to the Bupa Health Foundation before submitting the manuscript to the MJA.

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Narrative review

Chronic fatigue syndrome: progress and possibilities

Carolina X Sandler and Andrew R Lloyd

Med J Aust 2020; 212 (9): . || doi: 10.5694/mja2.50553
Published online: 6 April 2020

Topics

Infectious diseases

General medicine

Information science

Summary

Chronic fatigue syndrome (CFS) is a prevalent condition affecting about one in 100 patients attending primary care.
There is no diagnostic test, validated biomarker, clear pathophysiology or curative treatment.
The core symptom of fatigue affects both physical and cognitive activities, and features a prolonged post‐activity exacerbation triggered by tasks previously achieved without difficulty.
Although several different diagnostic criteria are proposed, for clinical purposes only three elements are required: recognition of the typical fatigue; history and physical examination to exclude other medical or psychiatric conditions which may explain the symptoms; and a restricted set of laboratory investigations.
Studies of the underlying pathophysiology clearly implicate a range of different acute infections as a trigger for onset in a significant minority of cases, but no other medical or psychological factor has been reproducibly implicated.
There have been numerous small case–control studies seeking to identify the biological basis of the condition. These studies have largely resolved what the condition is not: ongoing infection, immunological disorder, endocrine disorder, primary sleep disorder, or simply attributable to a psychiatric condition.
A growing body of evidence suggests CFS arises from functional (non‐structural) changes in the brain, but of uncertain character and location. Further functional neuroimaging studies are needed.
There is clear evidence for a genetic contribution to CFS from family and twin studies, suggesting that a large scale genome‐wide association study is warranted.
Despite the many unknowns in relation to CFS, there is significant room for improvement in provision of the diagnosis and supportive care. This may be facilitated via clinician education.

1 UNSW Fatigue Clinic, UNSW, Sydney, NSW
2 Queensland University of Technology, Brisbane, QLD
3 Kirby Institute for Infection and Immunity in Society, UNSW, Sydney, NSW
4 UNSW Medicine, Sydney, NSW

Correspondence: a.lloyd@unsw.edu.au

Acknowledgements:

Andrew Lloyd is supported by a National Health and Medical Research Council Practitioner Fellowship (1041897). We are grateful for the review of the manuscript by Phillip Peterson MD.

Competing interests:

No relevant disclosures.

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Letters

Time to recognise gout as a chronic disease

Helen I Keen, Philip C Robinson, Nicola Dalbeth and Catherine Hill

Med J Aust 2020; 212 (6): . || doi: 10.5694/mja2.50512
Published online: 6 April 2020

Topics

Musculoskeletal diseases

To the Editor: In August 2019, the Australian Institute of Health and Welfare (AIHW) released a report on chronic musculoskeletal conditions in Australia.1

1 Fiona Stanley Hospital, Perth, WA
2 Royal Perth Hospital, Perth, WA
3 University of Western Australia, Perth, WA
4 Centre for Neurogenetics and Statistical Genomics, Diamantina Institute, University of Queensland, Brisbane, QLD
5 Royal Brisbane and Women's Hospital, Brisbane, QLD
6 University of Auckland, Auckland, Auckland, New Zealand
7 Queen Elizabeth Hospital, Adelaide, SA
8 Royal Adelaide Hospital, Adelaide, SA

Correspondence: helen.keen@uwa.edu.au

Competing interests:

Nicola Dalbeth reports grants and personal fees from AstraZeneca, grants from Amgen, and personal fees from Dyve, Hengrui, Horizon, Abbvie, Pfizer, and Janssen outside the submitted work. Helen Keen reports personal fees from Abbvie, Cornerstones, Roche, and Pfizer outside of the submitted work.

1. Australian Institute of Health and Welfare. Arthritis [Cat. No. PHE 234]. Canberra: AIHW, 2019. https://www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/arthritis/related-material (viewed Jan 2019).
2. Pisaniello HL, Lester S, Gonzalez‐Chica D, et al. Gout prevalence and predictors of urate‐lowering therapy use: results from a population‐based study. Arthritis Res Ther 2018; 20: 143.
3. Rai SK, Choi HK, Choi SHJ, et al. Key barriers to gout care: a systematic review and thematic synthesis of qualitative studies. Rheumatology (Oxford) 2018; 57: 1282–1292.
4. Bursill D, Taylor WJ, Terkeltaub R, et al. Gout, Hyperuricaemia and Crystal‐Associated Disease Network (G‐CAN) consensus statement regarding labels and definitions of disease states of gout. Ann Rheum Dis 2019; 78: 1592–1600.
5. Dalbeth N, Schumacher HR, Fransen J, et al. Survey definitions of gout for epidemiologic studies: comparison with crystal identification as the gold standard. Arthritis Care Res (Hoboken) 2016; 68: 1894–1898.

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Letters

The hidden slaves of medicine

Sharon Sitters

Med J Aust 2020; 212 (6): . || doi: 10.5694/mja2.50510
Published online: 6 April 2020

Topics

Global health

Ethics and law

Social determinants of health

To the Editor: Nearly all industries profit from today's 25 million slaves and 150 million child labourers.1 The results of their work, including medical disposables, are sold worldwide. Unfortunately, there is not a comprehensive analysis identifying exactly where slaves are involved in the medical products supply chain.

Unitec Institute of Technology, Auckland, New Zealand

Correspondence: ssitters@unitec.ac.nz

Competing interests:

No relevant disclosures.

1. International Labour Organization. Modern slavery and child labour: 40 million in modern slavery and 152 million in child labour around the world. International Labour Organization, 2017. https://www.ilo.org/global/about-the-ilo/newsroom/news/WCMS_574717/lang-en/index.htm (viewed June 2019).
2. Bhutta MF. Time for a global response to labour rights violations in the manufacture of health‐care goods. Bull World Health Organ 2017; 95: 314–314A.
3. Bureau of International Labor Affairs. US Department of Labor's 2018 list of goods produced by child labor or forced labor. US Department of Labor, 2018. https://www.dol.gov/sites/dolgov/files/ILAB/ListofGoods.pdf (viewed June 2019).
4. Khadem N. Ansell says worker rights abuse in its supply chain under investigation. ABC News 2019, 11 Mar. https://www.abc.net.au/news/2019-01-04/ansell-investigating-claims-worker-rights-abuse-in-supply-chain/10685124 (viewed June 2019).
5. Boersma M. Do no harm? Procurement of medical goods by Australian companies and government. Australian Nursing and Midwifery Federation, Australia Institute, 2017. http://www.anmf.org.au/documents/Do_No_Harm_Report.pdf (viewed June 2019).
6. Nestlé. Tackling child labour — 2017 report. Nestlé, 2017. https://www.nestle.com/asset-library/documents/creating-shared-value/responsible-sourcing/nestle-cocoa-plan-child-labour-2017-report.pdf (viewed June 2019).
7. King B, Payne C, Melsom R. The tobacco free portfolios story [website]. Tobacco Free Portfolios, 2019. www.tobaccofreeportfolios.org/who-we-are/ (viewed Oct 2019).

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Research

Optimising epilepsy management with a smartphone application: a randomised controlled trial

Yang Si, Xiaoqiang Xiao, Cai Xia, Jiang Guo, Qiukui Hao, Qianning Mo, Yulong Niu and Hongbin Sun

Med J Aust 2020; 212 (6): . || doi: 10.5694/mja2.50520
Published online: 6 April 2020

Topics

Nervous system diseases

Health services administration

Information science

Abstract

Objective: To assess whether a practical intervention based upon a smartphone application (app) would improve self‐management and seizure control in adults with epilepsy.

Design, setting: Randomised, controlled trial in western China, December 2017 to August 2018.

Participants: 380 eligible people with epilepsy were recruited; 327 completed the 6‐month follow‐up (176 in the app group, 151 in the control group).

Main outcome measures: Self‐management of epilepsy (measured with the validated Chinese Epilepsy Self‐Management Scale, C‐ESMS) and self‐reported seizure frequency.

Results: In the intention‐to‐treat analysis, the mean C‐ESMS score increased significantly in the app group between baseline and the 6‐month evaluation (from 121.7 [SD, 12.1] to 144.4 [SD, 10.0]; P < 0.001); improvements on the information management, medication management, and safety management subscales were also statistically significant. At 6 months, the mean overall C‐ESMS score for the app group was significantly higher than that for the control group (125.4 [SD, 1.5]; P < 0.001). The proportion of patients who were seizure‐free at the 6‐month follow‐up was larger for the app than the control group (54 of 190, 28% v 22 of 190, 12%), as was the proportion with reductions in frequency of between 75 and 100% (22 of 190, 12% v 8 of 190, 4%). Changes in C‐ESMS score were not statistically associated with seizure frequency.

Conclusions: Using a smartphone app improved epilepsy self‐management scores in people in western China. It should be further tested in larger populations in other areas. Our preliminary investigation of building digital communities for people with epilepsy should encourage similar approaches to managing other chronic diseases.

Trial registration: Chinese Clinical Trial Registry, ChiCTR1900026864, 24 October 2019.

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1 Sichuan Academy of Medical Sciences and Sichuan People's Hospital, Chengdu, Sichuan, China
2 University of Electronic Science and Technology of China, Chengdu, Sichuan, China
3 Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Sciences and Sichuan People's Hospital, Chengdu, Sichuan, China
4 National Clinical Research Center for Geriatrics, Sichuan University West China Hospital, Chengdu, Sichuan, China
5 Key Laboratory of Bio‐Resource and Eco‐Environment, College of Life Sciences, Sichuan University, Chengdu, Sichuan, China

Correspondence:

yulong.niu@hotmail.com, sndxgl@163.com

Acknowledgements:

This investigation was supported by the National Natural Science Foundation of China (NSFC, 81701269).

Competing interests:

No relevant disclosures.

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