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Misgendering and experiences of stigma in health care settings for transgender people

Irene J Dolan, Penelope Strauss, Sam Winter and Ashleigh Lin
Med J Aust 2020; 212 (4): . || doi: 10.5694/mja2.50497
Published online: 2 March 2020

Misgendering negatively affects the mental and physical health of trans individuals

Misgendering occurs when a person is addressed or described using language that does not match their gender identity. Misgendering within the health care system can significantly affect the mental and physical health of transgender (hereafter trans) individuals and can negatively impact future engagement with the health care system. Systemic policies and practices create situations which increase the likelihood of misgendering and experience of stigma, affecting the delivery of health care to trans individuals.

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Bushfire smoke: urgent need for a national health protection strategy

Sotiris Vardoulakis, Bin B Jalaludin, Geoffrey G Morgan, Ivan C Hanigan and Fay H Johnston
Med J Aust 2020; 212 (8): . || doi: 10.5694/mja2.50511
Published online: 24 February 2020

More nuanced health advice is needed to protect populations and individuals from exposure to bushfire smoke

Bushfires have always been a feature of the natural environment in Australia, but the risk has increased over time as fire seasons start earlier, finish later, and extreme fire weather (ie, very hot, dry and windy conditions that make fires fast moving and very difficult to control) becomes more severe with climate change.,, The 2019–20 bushfires in Australia, particularly in New South Wales, Victoria, Queensland and the Australian Capital Territory, have caused at least 33 fatalities, extensive damage to property and destruction of flora and fauna, and have exposed millions of people to extreme levels of air pollution. Bushfire smoke, as well as smoke from prescribed burns, contains a complex mixture of particles and gases that are chemically transformed in the atmosphere and transported by the wind over long distances. In this context, a major public health concern is population exposure to atmospheric particulate matter (PM) with a diameter < 2.5 μm (PM2.5), which can penetrate deep into the respiratory system, inducing oxidative stress and inflammation, and even translocate into the bloodstream.

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  • 1 National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, ACT
  • 2 Ingham Institute for Applied Medical Research, University of New South Wales
  • 3 School of Public Health and University Centre for Rural Health, University of Sydney, Sydney, NSW
  • 4 Health Research Institute, University of Canberra, ACT
  • 5 Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS



Acknowledgements: 

This research was undertaken with support from the Australian National University College of Health and Medicine, and the assistance of resources from the Centre for Air pollution, energy and health Research (CAR). We used the CAR Data and Analysis Technology platform (https://cardat.github.io) to analyse data.

Competing interests:

Sotiris Vardoulakis has received funding support from the UK National Institute for Health Research, Medical Research Council, Natural Environment Research Council, Public Health England, EU Horizon 2020, and Dyson Ltd. Geoffrey Morgan and Ivan Hanigan receive funding support from the Australian National Health and Medical Research Council.

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  • 4. Johnston FH. Understanding and managing the health impacts of poor air quality from landscape fires. Med J Aust 2017; 207: 229–230. https://www.mja.com.au/journal/2017/207/6/understanding-and-managing-health-impacts-poor-air-quality-landscape-fires.
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Advances in type 2 diabetes therapy: a focus on cardiovascular and renal outcomes

Renata Libianto, Timothy ME Davis and Elif I Ekinci
Med J Aust 2020; 212 (3): . || doi: 10.5694/mja2.50472
Published online: 17 February 2020

Summary

  • Treatment options for type 2 diabetes have expanded. While metformin remains the first line treatment in most cases, choices for second line treatment now extend beyond sulfonylureas and include the sodium–glucose cotransporter 2 (SGLT2) inhibitors, glucagon‐like peptide 1 (GLP1) receptor agonists, and dipeptidyl peptidase 4 (DPP4) inhibitors.
  • SGLT2 inhibitors are recommended for people with atherosclerotic cardiovascular disease, heart failure or kidney disease. Diabetic ketoacidosis is an uncommon but important side effect; its occurrence can be minimised with appropriate patient education and management, especially during perioperative periods and times of illness.
  • GLP1 receptor agonists are recommended for people with atherosclerotic cardiovascular disease. Gastrointestinal side effects are common but are less prominent with the longer acting agents and can be minimised with slow titration of the shorter acting agents.
  • DPP4 inhibitors are generally well tolerated, but alogliptin and saxagliptin should be used with caution in people with risk factors for heart failure.
  • To optimise the management of type 2 diabetes, clinicians need to be aware of the pharmacological characteristics of each class of blood glucose‐lowering medications and of the effect on cardiovascular health and renal function, balanced by potential adverse effects.
  • Medications that have cardiovascular or renal benefits should be prescribed for patients with these comorbidities, and this is reflected in recent international guidelines.

  • 1 Melbourne University, Melbourne, VIC
  • 2 University of Western Australia, Perth, WA
  • 3 Austin Health, Melbourne, VIC


Correspondence: elif.ekinci@unimelb.edu.au

Acknowledgements: 

Renata Libianto is supported by a National Health and Medical Research Council/National Heart Foundation of Australia postgraduate scholarship and by the Royal Australasian College of Physicians (RACP). Timothy Davis is supported by a Medical Research Future Fund Next Generation Clinical Researchers Program Practitioner Fellowship. Elif Ekinci has received grant funding from Viertel, RACP, Sir Edward Weary Dunlop Medical Research Foundation, and Diabetes Australia Research Program.

Competing interests:

Elif Ekinci's institute has received research funding from Novo Nordisk, Sanofi, GeNeuro and Dimerix. Timothy Davis has served on advisory boards for, and received research funding, speaker fees and travel assistance to attend meetings from, Merck Sharp and Dohme (manufacturer of sitagliptin and ertugliflozin), NovoNordisk (manufacturer of liraglutide and semaglutide), and Eli Lilly (manufacturer of dulaglutide). He has also served on advisory boards for, and received speaker fees and travel assistance to attend meetings from, AstraZeneca (manufacturer of saxagliptin, exenatide and dapagliflozin) and Boehringer Ingelheim (manufacturer of linagliptin and empagliflozin).

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Incidence and prevalence of self‐reported non‐coeliac wheat sensitivity and gluten avoidance in Australia

Michael DE Potter, Michael P Jones, Marjorie M Walker, Natasha A Koloski, Simon Keely, Gerald Holtmann and Nicholas J Talley AC
Med J Aust 2020; 212 (3): . || doi: 10.5694/mja2.50458
Published online: 17 February 2020

Abstract

Objectives: To determine the incidence of self‐reported non‐coeliac wheat sensitivity (SR‐NCWS) and factors associated with its onset and resolution; to describe the prevalence of factors associated with gluten avoidance.

Design: Longitudinal cohort study; analysis of responses to self‐administered validated questionnaires (Digestive Health and Wellbeing surveys, 2015 and 2018).

Setting, participants: Subset of an adult population sample randomly selected in 2015 from the electoral rolls for the Newcastle and Gosford regions of New South Wales.

Main outcome measures: Prevalence of SR‐NCWS (2015, 2018) and incidence and resolution of SR‐NCWS, each by demographic and medical factors; prevalence of gluten avoidance and reasons for gluten avoidance (2018).

Results: 1322 of 2185 eligible participants completed the 2018 survey (response rate, 60.5%). The prevalence of SR‐NCWS was similar in 2015 (13.8%; 95% CI, 12.0–15.8%) and 2018 (13.9%; 95% CI, 12.1–15.9%); 69 of 1301 respondents (5.3%) reported developing new onset (incident) SR‐NCWS between 2015 and 2018 (incidence, 1.8% per year). Incident SR‐NCWS was significantly associated with a diagnosis of functional dyspepsia, and negatively associated with being male or older. Gluten avoidance was reported in 2018 by 24.2% of respondents (20.5% partial, 3.8% complete avoidance); general health was the most frequent reason for avoidance (168 of 316 avoiders, 53%). All 13 participants with coeliac disease, 56 of 138 with irritable bowel syndrome (41%), and 69 of 237 with functional dyspepsia (29%) avoided dietary gluten.

Conclusions: The prevalence of SR‐NCWS was similar in 2015 and 2018. Baseline (2015) and incident SR‐NCWS (2018) were each associated with functional gastrointestinal disorders. The number of people avoiding dietary gluten exceeds that of people with coeliac disease or SR‐NCWS, and general health considerations and abdominal symptoms are the most frequently reported reasons for avoidance.

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  • 1 University of Newcastle, Newcastle, NSW
  • 2 John Hunter Hospital, Newcastle, NSW
  • 3 Macquarie University, Sydney, NSW
  • 4 University of Queensland, Brisbane, QLD
  • 5 Princess Alexandra Hospital, Brisbane, QLD



Acknowledgements: 

This project was partially supported by a grant from Prometheus Laboratories.

Competing interests:

No relevant disclosures.

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The incidence of childhood cancer in Australia, 1983–2015, and projections to 2035

Danny R Youlden, Peter D Baade, Adèle C Green, Patricia C Valery, Andrew S Moore and Joanne F Aitken
Med J Aust 2020; 212 (3): . || doi: 10.5694/mja2.50456
Published online: 17 February 2020

Abstract

Objectives: To describe changes in childhood cancer incidence in Australia, 1983–2015, and to estimate projected incidence to 2035.

Design, setting: Population‐based study; analysis of Australian Childhood Cancer Registry data for the 20 547 children under 15 years of age diagnosed with cancer in Australia between 1983 and 2015.

Main outcome measures: Incidence rate changes during 1983–2015 were assessed by joinpoint regression, with rates age‐standardised to the 2001 Australian standard population. Incidence projections to 2035 were estimated by age‐period‐cohort modelling.

Results: The overall age‐standardised incidence rate of childhood cancer increased by 34% between 1983 and 2015, increasing by 1.2% (95% CI, +0.5% to +1.9%) per annum between 2005 and 2015. During 2011–2015, the mean annual number of children diagnosed with cancer in Australia was 770, an incidence rate of 174 cases (95% CI, 169–180 cases) per million children per year. The incidence of hepatoblastoma (annual percentage change [APC], +2.3%; 95% CI, +0.8% to +3.8%), Burkitt lymphoma (APC, +1.6%; 95% CI, +0.4% to +2.8%), osteosarcoma (APC, +1.1%; 95%, +0.0% to +2.3%), intracranial and intraspinal embryonal tumours (APC, +0.9%; 95% CI, +0.4% to +1.5%), and lymphoid leukaemia (APC, +0.5%; 95% CI, +0.2% to +0.8%) increased significantly across the period 1983–2015. The incidence rate of childhood melanoma fell sharply between 1996 and 2015 (APC, –7.7%; 95% CI, –10% to –4.8%). The overall annual cancer incidence rate is conservatively projected to rise to about 186 cases (95% CI, 175–197 cases) per million children by 2035 (1060 cases per year).

Conclusions: The incidence rates of several childhood cancer types steadily increased during 1983–2015. Although the reasons for these rises are largely unknown, our findings provide a foundation for health service planning for meeting the needs of children who will be diagnosed with cancer until 2035.

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  • 1 Cancer Council Queensland, Brisbane, QLD
  • 2 Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD
  • 3 Queensland University of Technology, Brisbane, QLD
  • 4 QIMR Berghofer Medical Research Institute, Brisbane, QLD
  • 5 Cancer Research UK Manchester Institute, Manchester University, Manchester, United Kingdom
  • 6 Children's Health, Queensland Hospital and Health Service, Brisbane, QLD
  • 7 Child Health Research Centre, University of Queensland, Brisbane, QLD
  • 8 Institute for Resilient Regions, University of Southern Queensland, Brisbane, QLD
  • 9 University of Queensland, Brisbane, QLD



Acknowledgements: 

Patricia Valery was supported by an NHMRC Career Development Fellowship (1083090). We thank Leisa O'Neill for her work in the Australian Childhood Cancer Registry. We also acknowledge the assistance of all Australian state and territory cancer registries, the Australian Institute of Health and Welfare, and each of the major paediatric oncology treating hospitals throughout Australia.

Competing interests:

No relevant disclosures.

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Implementing value‐based health care at scale: the NSW experience

Elizabeth Koff and Nigel Lyons
Med J Aust 2020; 212 (3): . || doi: 10.5694/mja2.50470
Published online: 17 February 2020

What is value in health care and how can the system deliver it at scale?

The New South Wales health system exemplifies the worldwide challenge of health service sustainability. With 234 public hospitals and facilities employing over 130 000 staff, the system provides universal access to health care for a growing population of almost 8 million people across a diverse geography of over 800 000 km2. The NSW Health budget in 2018–19 was $25 billion, representing over 25% of the annual state budget. As with all health systems, NSW Health is experiencing growing pressure from chronic disease, an ageing population and the use of new technology. In response, optimising health system access and efficiency has been central to health reform in NSW.


  • NSW Health, Sydney, NSW



Competing interests:

No relevant disclosures.

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First statewide meningococcal B vaccine program in infants, children and adolescents: evidence for implementation in South Australia

Helen S Marshall, Noel Lally, Louise Flood and Paddy Phillips
Med J Aust 2020; 212 (2): . || doi: 10.5694/mja2.50481
Published online: 3 February 2020

Summary

  • Invasive meningococcal disease (IMD) is an uncommon but life‐threatening infection caused by Neisseria meningitidis. Serogroups B, C, W and Y cause most IMD cases in Australia. The highest incidence occurs in children under 5 years of age. A second peak occurs in adolescents and young adults, which is also the age of highest carriage prevalence of N. meningitidis.
  • Meningococcal serogroup B (MenB) disease predominated nationally before 2016 and has remained the predominant cause of IMD in South Australia with 82% of cases, compared with 35% in New South Wales, 35% in Queensland, 9% in Victoria, 29% in Western Australia and 36% nationally in 2016.
  • MenB vaccination is recommended by the Australian Technical Advisory Group on Immunisation for infants up to 2 years of age and adolescents aged 15–19 years (age 15–24 years for at‐risk groups, such as people living in close quarters or smokers), laboratory workers with exposure to N. meningitidis, and Aboriginal and Torres Strait Islander children from age 2 months to 19 years.
  • Due to the epidemiology and disease burden from MenB, a meningococcal B vaccine program has been implemented in South Australia for individuals with age‐specific incidence rates higher than the mean rate of 2.8/100 000 population in South Australia in the period 2000–2017, including infants, young children (< 4 years) and adolescents (15–20 years).
  • Program evaluation of vaccine effectiveness against IMD is important. As observational evidence also suggests 4CMenB may have an impact on Neisseria gonorrhoeae with genetic homology between bacterial species, the vaccine impact on gonorrhoea will also be assessed.

  • 1 Women's and Children's Health Network, Adelaide, SA
  • 2 Robinson Research Institute, University of Adelaide, Adelaide, SA
  • 3 Communicable Disease Control Branch, Department for Health and Wellbeing, , Adelaide, SA



Acknowledgements: 

Helen Marshall is supported by the National Health and Medical Research Council: Career Development Fellowship (1084951). We thank Rodney Pearce and Celia Cooper, members of the South Australian Meningococcal B Expert Working Group, for reviewing the manuscript.

Competing interests:

The University of Adelaide, Helen Marshall's employer, has received funding from GlaxoSmithKline and Pfizer to undergo investigator‐led research. Helen Marshall is a member of ATAGI, but the views expressed in this article are her own views. She does not receive any personal payments from the pharmaceutical industry.

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Caesarean section births for twins: rational choice, or a non‐evidence‐based intervention that may cause harm?

David A Ellwood
Med J Aust 2020; 212 (2): . || doi: 10.5694/mja2.50454
Published online: 3 February 2020

The change from vaginal births to operative births may entail unforeseen longer term consequences

The benefits and risks of birth by caesarean section are debated, with passionate proponents on each side of the discussion. The most recent national data (for 2017) indicate that in Australia more than one‐third of babies (35%) were born after caesarean section. While its safety has undoubtedly improved, it is still reported that greater maternal and perinatal morbidity and mortality are associated with caesarean section than with vaginal births. The longer term health outcomes for mother and child are also important. In this issue of the MJA, Liu and her colleagues report that the caesarean rate for twin pregnancies in Victoria has almost tripled over the past three decades, and that the most frequent reason for operative intervention was the twin pregnancy itself. It is pertinent to examine the reasons for this trend and to ask whether it is justified.


  • 1 Griffith University, Gold Coast, QLD
  • 2 Gold Coast University Hospital, Gold Coast, QLD


Correspondence: d.ellwood@griffith.edu.au

Competing interests:

No relevant disclosures.

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The cheques and balances of national universal screening of patients with new colorectal cancer for Lynch syndrome

Megan Hitchins
Med J Aust 2020; 212 (2): . || doi: 10.5694/mja2.50453
Published online: 3 February 2020

Tiered universal screening systems that save lives are cost‐effective

About 15–20% of colorectal cancers exhibit microsatellite instability (MSI) caused by deficient DNA mismatch repair (MMR). Most of these cancers (80%) are sporadic, associated with hypermethylation of the MLH1 gene promoter. Lynch syndrome is caused by germline mutations affecting one of the MMR genes (MLH1, MSH2, MSH6, PMS2), and accounts for 15–20% of MMR‐deficient (dMMR) colorectal cancers, or 2–5% of all colorectal cancers, making it the most common hereditary colorectal cancer predisposition syndrome. People with Lynch syndrome are at increased risk of several cancer types, especially colorectal cancer: the risk by age 70 years is 10–82%, depending on the mutant gene, considerably higher than that of the general population (4.5%).


  • Cedars‐Sinai Center for Bioinformatics and Functional Genomics, Los Angeles, CA, United States of America


Correspondence: megan.hitchins@cshs.org

Competing interests:

No relevant disclosures.

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Use of botulinum toxin to heal atypical pressure ulcers in the palm

Anupam Datta Gupta and David H Wilson
Med J Aust 2020; 212 (2): . || doi: 10.5694/mja2.50452
Published online: 3 February 2020

A 59‐year‐old woman attended our spasticity clinic with treatment‐resistant atypical pressure ulcer in the right hand caused by focal spasticity secondary to upper motor neuron lesion. She had suffered subarachnoid haemorrhage from a ruptured arteriovenous malformation and underwent craniotomy. She was deemed not suitable for structured rehabilitation due to her significant disability and was placed in a residential accommodation. The patient was using an electrical wheelchair and was requiring full assistance with her personal care. She had typical, dense post‐stroke right‐sided spastic hemiplegia. In the upper limb, she had shoulder adduction and internal rotation, elbow flexion, wrist palmar flexion with flexed fingers at the metacarpophalangeal and proximal interphalangeal joints. She had a baclofen pump that controlled her lower limb spasticity.


  • 1 Queen Elizabeth Hospital, Adelaide, SA
  • 2 University of Adelaide, Adelaide, SA



Acknowledgements: 

We thank Barbara Brougham for her help with the editing of the manuscript.

Competing interests:

No relevant disclosures.

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