MJA
MJA

    Ending cheap alcohol gets promising results

    Mike Daube and Julia Stafford
    Med J Aust 2020; 212 (5): . || doi: 10.5694/mja2.50515
    Published online: 16 March 2020

    The evidence from real world implementation is compelling

    There is no shortage of evidence‐based recommendations regarding measures for reducing the considerable health and social harms associated with alcohol misuse in Australia and elsewhere1 — nor of opposition from the powerful alcohol industry and its allies to anything that might be effective. Their counter‐arguments, here as elsewhere, are all too familiar: voluntary approaches are best; anything that might reduce alcohol harms is draconian, penalises ordinary consumers, and interferes with individual liberties; no one measure will solve the problem overnight; more research is needed — and above all, as in other areas, nothing should ever be done for the first time.2

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      Time to develop guidelines for screening and management of atrial fibrillation in Indigenous Australians

      Nicole Lowres and Ben Freedman
      Med J Aust 2020; 212 (5): . || doi: 10.5694/mja2.50513
      Published online: 16 March 2020

      Screening guidelines specific to the needs of Australia's Indigenous population are needed

      One‐third of all ischaemic strokes are associated with atrial fibrillation (AF).1 Over the next 15 years, the number of AF‐related strokes in Australia is likely to rise substantially because of the predicted rise in AF prevalence.2 It is conservatively estimated that by 2034 more than 600 000 people in Australia will have AF, but these numbers do not take into account the higher prevalence of AF among Indigenous Australians.2 The prevalence of AF among hospitalised Indigenous patients under 60 years of age was reported by one study to be 2.57%, compared with 1.73% for non‐Indigenous patients.3 These hospital‐specific figures possibly underestimate prevalence, however, as they do not include cases of AF detected in Indigenous medical centres or general practices, or people with undiagnosed AF.

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      • Heart Research Institute, Charles Perkins Centre, University of Sydney, Sydney, NSW


      Correspondence: nicole.lowres@sydney.edu.au
      Acknowledgements: 

      Nicole Lowres is funded by a NSW Health Early Career Fellowship (H16/52168).

      Competing interests:

      Ben Freedman has previously received fees and advisory board honoraria from Bayer, Daiichi‐Sankyo, and Pfizer/Bristol‐Myers Squibb, and an honorarium from Omron. Ben Freedman and Nicole Lowres have received investigator‐initiated grants from Pfizer and Bristol‐Myers Squibb.

      • 1. Friberg L, Rosenqvist M, Lindgren A, et al. High prevalence of atrial fibrillation among patients with ischemic stroke. Stroke 2014; 45: 2599–2605.
      • 2. Ball J, Thompson DR, Ski CF, et al. Estimating the current and future prevalence of atrial fibrillation in the Australian adult population. Med J Aust 2015; 202: 32–35. https://www.mja.com.au/journal/2015/202/1/estimating-current-and-future-prevalence-atrial-fibrillation-australian-adult.
      • 3. Wong CX, Brooks AG, Cheng YH, et al. Atrial fibrillation in Indigenous and non‐Indigenous Australians: a cross‐sectional study. BMJ Open 2014; 4: e006242.
      • 4. Nedkoff L, Kelty EA, Hung J, et al. Stroke risk and cardiovascular mortality for Aboriginal and other Australian patients with atrial fibrillation. Med J Aust 2020; 212: 215–222.
      • 5. Katzenellenbogen JM, Woods JA, Teng TH, Thompson SC. Atrial fibrillation in the Indigenous populations of Australia, Canada, New Zealand, and the United States: a systematic scoping review. BMC Cardiovasc Disord 2015; 15: 87.
      • 6. Poppe K, Rambaldini B, Rolleston A, et al. Atrial fibrillation among indigenous populations globally. Heart Lung Circ 2019; 28 Suppl 2: S39–S40.
      • 7. He VYF, Condon John R, Ralph AP, et al. Long‐term outcomes from acute rheumatic fever and rheumatic heart disease. Circulation 2016; 134: 222–232.
      • 8. Healey JS, Connolly SJ, Gold MR, et al; ASSERT Investigators. Subclinical atrial fibrillation and the risk of stroke. New Engl J Med 2012; 366: 120–129.
      • 9. NHFA CSANZ Atrial Fibrillation Guideline Working Group; Brieger D, Amerena J, Attia J, et al. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the diagnosis and management of atrial fibrillation 2018. Heart Lung Circ 2018; 27: 1209–1266.
      • 10. Gwynne K, Flaskas Y, Brien C, et al. Opportunistic screening to detect atrial fibrillation in Aboriginal adults in Australia. BMJ Open 2016; 6: e013576.
      • 11. Macniven R, Gwynn J, Fujimoto H, et al. Feasibility and acceptability of opportunistic screening to detect atrial fibrillation in Aboriginal adults. Aust N Z J Public Health 2019; 43: 313–318.
      • 12. Bellinge JW, Paul JJ, Walsh LS, et al. The impact of non‐vitamin K antagonist oral anticoagulants (NOACs) on anticoagulation therapy in rural Australia. Med J Aust 2018; 208: 18–23. https://www.mja.com.au/journal/2018/208/1/impact-non-vitamin-k-antagonist-oral-anticoagulants-noacs-anticoagulation
      • 13. Wong CX, Lee SW, Gan SW, et al. Underuse and overuse of anticoagulation for atrial fibrillation: a study in Indigenous and non‐Indigenous Australians. Int J Cardiol 2015; 191: 20–24.
      • 14. Balabanski AH, Newbury J, Leyden JM, et al. Excess stroke incidence in young Aboriginal people in South Australia: Pooled results from two population‐based studies. Int J Stroke 2018; 13: 811–814.
      • 15. Zhang J, Tang J, Cui X, et al. Indirect comparison of novel oral anticoagulants among Asians with non‐valvular atrial fibrillation in the real world setting: a network meta‐analysis. BMC Cardiovasc Disord 2019; 19: 182.
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        More than a refresh required for closing the gap of Indigenous health inequality

        Chelsea J Bond and David Singh
        Med J Aust 2020; 212 (5): . || doi: 10.5694/mja2.50498
        Published online: 16 March 2020

        If we are committed to closing the gap, we should be committed to transforming relationships of power between Indigenous and non‐Indigenous people

        After over a decade of tabling annual reports of policy failure in Closing the Gap in Indigenous health inequality, the Morrison government announced in 2019 a refresh of the targets, rather than a rethink of the policy approach.1 This refresh includes a process of Indigenous consultation and codesign via the Coalition of the Peaks (a representative body of about 40 Aboriginal and Torres Strait Islander organisations), which makes for a refreshing change in Indigenous health policy.2 Whether such engagement will engender the radical reimagining required to transform persisting Indigenous health disparities remains to be seen.

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        • University of Queensland, Brisbane, QLD


        Correspondence: c.bond3@uq.edu.au
        Acknowledgements: 

        Chelsea Bond is a recipient of an Australian Research Council Discovery Early Career Research Fellowship.

        Competing interests:

        No relevant disclosures.

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          Antiplatelet therapy within 30 days of percutaneous coronary intervention with stent implantation

          Benjumin Hsu, Michael O Falster, Andrea L Schaffer, Sallie Pearson, Louisa Jorm and David B Brieger
          Med J Aust 2020; 213 (3): . || doi: 10.5694/mja2.50507
          Published online: 9 March 2020

          Percutaneous coronary intervention with stent implantation (PCI‐S) has revolutionised the management of patients with coronary artery disease at high risk of myocardial infarction and stroke.1 Dual antiplatelet therapy (aspirin with clopidogrel, prasugrel or ticagrelor) is superior to aspirin alone for preventing atherothrombotic events, including stent thrombosis, in patients undergoing PCI‐S,2 and is recommended by Australian guidelines.3

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          • 1 Centre for Big Data Research in Health, UNSW Australia, Sydney, NSW
          • 2 Menzies Centre for Health Policy, University of Sydney, Sydney, NSW
          • 3 Concord Repatriation General Hospital, Sydney, NSW


          Correspondence: benjumin.hsu@unsw.edu.au
          Competing interests:

          No relevant disclosures.

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            Blood lead levels in children have fallen, but vigilance is still needed

            Mark P Taylor and Bruce P Lanphear
            Med J Aust 2020; 212 (4): . || doi: 10.5694/mja2.50495
            Published online: 2 March 2020

            Ongoing population‐level strategies are needed to further reduce lead exposure

            The largest survey of blood lead levels in children in Australia outside high risk mining and smelting communities since the phasing out of leaded petrol was undertaken as part of the Barwon Infant Study in Victoria. As reported in this issue of the MJA,1 the investigators found that blood lead concentrations in children were considerably lower (geometric mean, 0.95 μg/dL) than those measured in the last major survey of Australian children, more than 25 years ago (geometric mean, 5.05 μg/dL).2 Blood lead levels have declined dramatically over the past 50 years,3,4 and Symeonides and colleagues have found that levels in children continue to fall. Nevertheless, they are still about 60 times higher than in pre‐industrial humans (0.016 μg/dL),5 and health agencies have declared that there is no safe level of lead for children.6,7


            • 1 Macquarie University, Sydney, NSW
            • 2 Simon Fraser University, Burnaby, BC, Canada


            Correspondence: mark.taylor@mq.edu.au
            Competing interests:

            Mark Patrick Taylor is affiliated with the Broken Hill Lead Reference Group, The LEAD Group (Australia), and the Broken Hill Environmental Lead Program of the NSW Environmental Protection Agency (EPA). He has received funding from the Broken Hill Environmental Lead Program for lead‐related research; Australian federal government Citizen Science grants for the project, “Citizen insights to the composition and risks of household dust” (CSG55984); from the Australian Research Council (ARC) for perfluorinated alkylated substances (PFAS)‐related research (SR180100021), an ARC Special Research Initiative Collaboration Agreement; an ARC Linkage grant (with Rio Tinto) for “Improved control of dioxin emissions during iron ore sintering”; and from the Metropolitan Fire Brigade (Victoria) for a clinical trial of PFAS removal from firefighters by phlebotomy. Mark Patrick Taylor has also prepared commissioned reports and provided expert advice on environmental contamination and human health for a range of bodies, including the Australian Building Codes Board (lead in plumbing fittings and materials), lawyers, governments, union agencies, and private companies. He has also received funding from Macquarie University for sabbatical research and major equipment purchases. Bruce Lanphear serves as an expert witness in plaintiff cases of childhood lead poisoning in Milwaukee (WI) and Flint (MI) in the United States, but receives no personal compensation.

            • 1. Symeonides C, Vuillermin P, Sly PD, et al. Pre‐school child blood lead levels in a population‐derived Australian birth cohort: the Barwon Infant Study. Med J Aust 2019; 211: 169–174.
            • 2. Donovan J. Lead in Australian children. Report on the national survey of lead in children. Canberra: Australian Institute of Health and Welfare, 1996. https://www.aihw.gov.au/getmedia/b6d0e6d2-09f1-4ef1-b62b-a0930557509b/lead-in-australian-children.pdf.aspx?inline=true (viewed Aug 2019).
            • 3. Kristensen LJ, Taylor MP, Flegal AR. An odyssey of environmental pollution: the rise, fall and remobilisation of industrial lead in Australia. Applied Geochemistry 2017; 83: 3–13.
            • 4. Robbins N, Zhang Z‐F, Sun J, et al. Childhood lead exposure and uptake in teeth in the Cleveland area during the era of leaded gasoline. Sci Total Environ 2010; 408: 4118–4127.
            • 5. Flegal AR, Smith DR. Lead levels in preindustrial humans. N Engl J Med 1992; 326: 1293–1294.
            • 6. Centers for Disease Control and Prevention. Childhood lead poisoning prevention. July 2019. https://www.cdc.gov/nceh/lead/prevention/default.htm (viewed Nov 2019)
            • 7. World Health Organization. Lead poisoning and health. Aug 2019. https://www.who.int/news-room/fact-sheets/detail/lead-poisoning-and-health (viewed Nov 2019).
            • 8. Canfield RL, Henderson CR, Cory‐Slechta DA, et al. Intellectual impairment in children with blood lead concentrations below 10 μg per deciliter. N Engl J Med 2003; 348: 1517–1526.
            • 9. Budtz‐Jørgensen E, Bellinger D, Lanphear B, et al. An international pooled analysis for obtaining a benchmark dose for environmental lead exposure in children. Risk Anal 2013; 33: 450–461.
            • 10. Reuben A, Schaefer JD, Moffitt TE, et al. Association of childhood lead exposure with adult personality traits and lifelong mental health. JAMA Psychiatry 2019; 76: 418–425.
            • 11. Lanphear BP, Rauch S, Auinger P, et al. Low‐level lead exposure and mortality in US adults: a population‐based cohort study. Lancet Public Health 2018; 3: e177–e184.
            • 12. Reuben A, Caspi A, Belsky DW, et al. Association of childhood blood lead levels with cognitive function and socioeconomic status at age 38 years and with IQ change and socioeconomic mobility between childhood and adulthood. JAMA 2017; 317: 1244–1251.
            • 13. National Toxicology Program. Health effects of low‐level lead (NTP monograph). U.S. Department of Health and Human Services, June 2012. https://ntp.niehs.nih.gov/ntp/ohat/lead/final/monographhealtheffectslowlevellead_newissn_508.pdf (viewed Aug 2019).
            • 14. Lanphear BP. Low‐level toxicity of chemicals: no acceptable levels? PLoS Biol 2017; 15: e2003066.
            • 15. National Health and Medical Research Council. Managing individual exposure to lead in Australia: a guide for health practitioners. Canberra: NHMRC, 2016. https://www.nhmrc.gov.au/about-us/publications/managing-individual-exposure-lead-australia (viewed Nov 2019.
            • 16. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey (NHANES): blood lead levels in the US population. Updated July 2019. https://www.cdc.gov/nceh/lead/data/nhanes.htm (viewed Aug 2019).
            • 17. Taylor MP, Harvey PJ, Morrison AM. Lead in plumbing products and materials. June 2018. https://www.abcb.gov.au/Resources/Publications/Consultation/Lead-in-Plumbing-Products-and-Materials (viewed Sept 2019).
            • 18. Shaffer RM, Gilbert SG. Reducing occupational lead exposures: strengthened standards for a healthy workforce. NeuroToxicology 2018; 69: 181–186.
            • 19. Safe Work Australia. Lead. Updated July 2019. https://www.safeworkaustralia.gov.au/topic/lead (viewed Aug 2019).
            • 20. Navas‐Acien A, Tellez‐Plaza M, Guallar E, et al. Blood cadmium and lead and chronic kidney disease in US adults: a joint analysis. Am J Epidemiol 2009; 170: 1156–1164.
            • 21. Kamel F, Umbach DM, Hu H, et al. Lead exposure as a risk factor for amyotrophic lateral sclerosis. Neurodegener Dis 2005; 2: 195–201.
            • 22. Bakulski KM, Rozek LS, Dolinoy DC, et al. Alzheimer's disease and environmental exposure to lead: the epidemiologic evidence and potential role of epigenetics. Curr Alzheimer Res 2012; 9: 563–573.
            • 23. Health Canada. Fourth Report on human biomonitoring of environmental chemicals in Canada. Aug 2017. https://www.canada.ca/en/health-canada/services/environmental-workplace-health/reports-publications/environmental-contaminants/fourth-report-human-biomonitoring-environmental-chemicals-canada.html (viewed Sept 2019).
            • 24. Nussbaumer‐Streit B, Yeoh B, Griebler U, et al. Household interventions for preventing domestic lead exposure in children. Cochrane Database Syst Rev 2016; CD006047.
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              Overdiagnosis of cancer in Australia: the role of screening

              David M Roder and Elizabeth Buckley
              Med J Aust 2020; 212 (4): . || doi: 10.5694/mja2.50494
              Published online: 2 March 2020

              The balance between benefits and risks could be improved if effective risk‐based screening protocols were developed

              Overdiagnosis can be defined as the proportion of diagnosed cancers that would not otherwise have come to a person's attention during their lifetime.1,2 Overdiagnosis provides no benefit to the patient but can have financial, psychosocial, and health consequences.2 While advances in imaging and other screening and diagnostic technologies can lead to therapeutic benefit, they can also increase overdiagnosis. Because overdiagnosed cancers are generally indistinguishable from potentially lethal cancers, the imperative to treat is equivalent.2


              • Cancer Research Institute, University of South Australia, Adelaide, SA


              Correspondence: david.roder@unisa.edu.au
              Competing interests:

              No relevant disclosures.

              • 1. Brodersen J, Schwartz LM, Heneghan C, et al. Overdiagnosis: what is it and what it isn't. BMJ Evid Based Med 2018; 23: 1–3.
              • 2. Marmot MG, Altman DG, Cameron DA, et al. The benefits and harms of breast cancer screening: an independent review. Br J Cancer 2013; 108: 2205–2240.
              • 3. Rainey L, van der Waal D, Jervaeus A, et al. Are we ready for the challenge of implementing risk‐based breast cancer screening and primary prevention? Breast 2018; 39: 24–32.
              • 4. Glasziou PP, Jones MA, Pathirana T, et al. Estimating the magnitude of cancer overdiagnosis in Australia. Med J Aust 2020; 212: 163–168.
              • 5. Esserman LJ, Thompson IM, Reid B, et al. Addressing overdiagnosis and overtreatment in cancer: a prescription for change. Lancet Oncol 2014; 15: e234–e242.
              • 6. Njor SH, Garne JP, Lynge E. Over‐diagnosis estimate from The Independent UK Panel on Breast Cancer Screening is based on unsuitable data. J Med Screen 2013; 20: 104–105.
              • 7. Morrell S, Gregory M, Sexton K, et al. Absence of sustained breast cancer incidence inflation in a national mammography screening programme. J Med Screen 2019; 26: 26–34.
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                How to perform a skin biopsy

                Kirsty JL Wark, Saxon D Smith and Deshan F Sebaratnam
                Med J Aust 2020; 212 (4): . || doi: 10.5694/mja2.50473
                Published online: 2 March 2020

                The skin has more disease processes than any other organ system in medicine, with over 3000 dermatological conditions described.1 Teaching of dermatology is often neglected in medical training internationally, and most doctors feel ill‐equipped to diagnose cutaneous pathology.2 Compounding this, limitations in access to specialist dermatologists in Australia are well recognised.3 Fortunately, biopsy of the skin is a simple skill to learn which can greatly help with the diagnosis of dermatological diseases. For cutaneous malignancies, the diagnosis is principally based on histopathological findings. However, for rashes, the correlation between clinical and pathological findings is paramount. For instance, observation of a lichenoid reaction pattern on skin biopsy may reflect lichen planus, lupus, dermatomyositis, lichen sclerosus, cutaneous T cell lymphoma, or graft‐versus‐host disease. To maximise the diagnostic yield of a skin biopsy, an understanding of the different types of biopsy, their indications and limitations is vital (Box 1 and Box 2).


                • 1 Liverpool Hospital, Sydney, NSW
                • 2 Royal North Shore Hospital, Sydney, NSW
                • 3 University of Sydney, Sydney, NSW
                • 4 Sydney Children's Hospitals Network, Sydney, NSW


                Correspondence: deshan@unsw.edu.au


                Series editors

                Balakrishnan (Kichu) Nair

                Simon O'Connor

                Acknowledgements: 

                We thank Alicia O'Connor, Anes Yang, Victoria Venning, Imogen Faulds and our patients for their contributions to the clinical images.

                Competing interests:

                No relevant disclosures.

                • 1. Bickers DR, Lim HW, Margolis D, et al. The burden of skin diseases: 2004: a joint project of the American Academy of Dermatology Association and the Society for Investigative Dermatology. J Am Acad Dermatol 2006; 55: 490–500.
                • 2. Hussain W, Hafiji J, Stanley AG, Khan KM. Dermatology and junior doctors: an evaluation of education, perceptions and self‐assessed competencies. Br J Dermatol 2008; 159: 505–506.
                • 3. Sebaratnam DF, Murrell DF. Dermatology training and practice in Australia. Int J Dermatol 2014; 53: 1259–1264.
                • 4. de Menezes SL, Kelly JW, Wolfe R, et al. The increasing use of shave biopsy for diagnosing invasive melanoma in Australia. Med J Aust 2019; 211: 213–218. https://www.mja.com.au/journal/2019/211/5/increasing-use-shave-biopsy-diagnosing-invasive-melanoma-australia
                • 5. Elston DM, Stratman EJ, Miller SJ. Skin biopsy: biopsy issues in specific diseases. J Am Acad Dermatol 2016; 74: 1–16.
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                  Hidden in plain sight: umbilical melanoma

                  Tom Kovitwanichkanont, Shoba Joseph and Leona Yip
                  Med J Aust 2020; 212 (4): . || doi: 10.5694/mja2.50490
                  Published online: 2 March 2020

                  A 74‐year‐old Caucasian woman was referred for hirsutism over the abdomen and was incidentally found to have a 21 × 25 mm ulcerated nodule over the umbilicus (Box 1). This occurred on the background of a longstanding lesion. Over the previous 6 months, the nodule had become ulcerated and occasionally bled. The remainder of the full skin examination was unremarkable, with no concerning lesions or palpable regional lymphadenopathy. She had no previous malignancy but had a strong family history of colorectal, breast, lung and pharyngeal cancer. Results of investigations to exclude internal malignancies were normal. Following an initial incisional biopsy demonstrating malignant amelanotic melanoma, a subsequent wide local excision confirmed this to be a stage IIIC, extensively ulcerated invasive nodular melanoma of 21 mm thickness and Clark level IV, with a mitotic rate of up to 15/mm2. There was no lymphovascular or perineural invasion. Microsatellites, desmoplasia and regression were not identified. The melanoma was BRAF negative on both immunohistochemical and molecular testing. Sentinel lymph node biopsy showed two metastatic melanoma deposits in the left inguinal sentinel node. Initial staging evaluations showed no evidence of nodal or distant metastases on whole body positron emission tomography–computed tomography (PET–CT) and brain magnetic resonance imaging (MRI). The patient was commenced on adjuvant nivolumab immunotherapy, but 4 months into treatment was confirmed by biopsy to have recurrent left inguinal nodal metastatic disease, and a repeat PET–CT scan showed possible in‐transit metastasis in the abdominal wall. Dissection of the involved ilioinguinal lymph node and ultrasound‐guided removal of the abdominal metastatic deposit were being planned at the time of writing.


                  • 1 Skin Health Institute, Melbourne, VIC
                  • 2 Sinclair Dermatology, Melbourne, VIC
                  • 3 Barton Specialist Centre, Canberra, ACT


                  Acknowledgements: 

                  We thank Miklos Pohl OAM and Dr Genevieve Bennett for their contributions to patient care.

                  Competing interests:

                  No relevant disclosures.

                  • 1. Papalas JA, Selim MA. Metastatic vs primary malignant neoplasms affecting the umbilicus: clinicopathologic features of 77 tumors. Ann Diagn Pathol 2011; 15: 237–242.
                  • 2. Campos‐Munoz L, Quesada‐Cortes A, Ruiz E, et al. Primary melanoma of the umbilicus appearing as omphalitis. Clin Exp Dermatol 2007; 32: 322–324.
                  • 3. Colonna MR, Giovannini UM, Sturniolo G, Colonna U. The umbilicus: a rare site for melanoma. Clinical considerations in two cases. Case reports. Scand J Plast Reconstr Surg Hand Surg 1999; 33: 449–452.
                  • 4. Steck WD, Helwig EB. Tumors of the umbilicus. Cancer 1965; 18: 907–915.
                  • 5. Mar V, Roberts H, Wolfe R, et al. Nodular melanoma: a distinct clinical entity and the largest contributor to melanoma deaths in Victoria, Australia. J Am Acad Dermatol 2013; 68: 568–575.
                  • 6. Gabriele R, Conte M, Egidi F, Borghese M. Umbilical metastases: current viewpoint. World J Surg Oncol 2005; 3: 13.
                  • 7. Cancer Council Australia Melanoma Guidelines Working Party. Clinical practice guidelines for the diagnosis and management of melanoma. Sydney: Cancer Council Australia. 2019. https://wiki.cancer.org.au/australia/Guidelines:Melanoma (viewed Dec 2019).
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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.1 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.


                    • 1 HealthPathways WA, Perth, WA
                    • 2 Telethon Kids Institute, Perth, WA
                    • 3 University of Western Australia, Perth, WA
                    • 4 Curtin University, Perth, WA


                    Correspondence: irene.dolan@wapha.org.au
                    Acknowledgements: 

                    Ashleigh Lin is supported by a National Health and Medical Research Council Career Development Fellowship (1148793).

                    Competing interests:

                    No relevant disclosures.

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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.1,2,3 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.4 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,5 and even translocate into the bloodstream.6

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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.

                      • 1. Harris S, Lucas C. Understanding the variability of Australian fire weather between 1973 and 2017. PLoS One 2019; 14: e0222328.
                      • 2. Di Virgilio G, Evans JP, Blake SAP, et al. Climate change increases the potential for extreme wildfires. Geophys Res Lett 2019; 46: 8517–8526.
                      • 3. 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 2019; 211: 490–491.e21. https://www.mja.com.au/journal/2019/211/11/2019-report-mja-lancet-countdown-health-and-climate-change-turbulent-year-mixed
                      • 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.
                      • 5. Lodovici M, Bigagli E. Oxidative stress and air pollution exposure. J Toxicol 2011; 2011: 487074.
                      • 6. Brook RD, Rajagopalan S, Pope CA 3rd, et al. Particulate matter air pollution and cardiovascular disease: an update to the scientific statement from the American Heart Association. Circulation 2010; 121: 2331–2378.
                      • 7. Morgan G, Sheppeard V, Khalaj B, et al. Effects of bushfire smoke on daily mortality and hospital admissions in Sydney. Australia. Epidemiology 2010; 21: 47–55.
                      • 8. Martin KL, Hanigan IC, Morgan GG, et al. Air pollution from bushfires and their association with hospital admissions in Sydney, Newcastle and Wollongong, Australia 1994‐2007. Aust. N Z J Public Health 2013; 37: 238–243.
                      • 9. Johnston FH, Purdie S, Jalaludin B, et al. Air pollution events from forest fires and emergency department attendances in Sydney, Australia 1996‐2007: a case‐crossover analysis. Environ Health 2014; 13: 105.
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