MJA
MJA

    Pill‐testing as a harm reduction strategy: time to have the conversation

    Jody Morgan and Alison Jones
    Med J Aust 2019; 211 (10): . || doi: 10.5694/mja2.50385
    Published online: 4 November 2019

    Despite harm reduction being a pillar of the Australian National Drug Strategy, current governments are shying away from pill‐testing as a viable strategy

    The recent deaths of five young Australians at music festivals has once again placed pill‐testing at the forefront of media discussion. Rates of drug use are significantly higher among certain subpopulations, with dance music nightclubs and music festivals being examples of places with elevated levels of drug use.1,2 Of 642 surveyed attendees at an Australian music festival, 73.4% reported drug taking compared with 28.2% of the general young adult population, and for 3,4‐methylenedioxymethamphetamine (MDMA; commonly known as ecstasy) use, this was as high as 59.8% compared with 7.0%.2 MDMA is increasingly available in powder and crystal forms with street names of molly, mandy and crystal, meaning some users do not associate the drug with ecstasy.

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      Moving beyond stepped care to staged care using a novel, technology‐enabled care model for youth mental health

      Ian B Hickie
      Med J Aust 2019; 211 (9): . || doi: 10.5694/mja2.50379
      Published online: 4 November 2019

      This model of care emphasises not only early access to assessment across a number of clinical and functional domains but also rapid and ongoing provision of stage‐appropriate interventions

      Australia can rightly claim to lead the world in mental health awareness, especially for the mental health and wellbeing of young people.1 However, despite the development of designated primary care‐style services (eg, headspace),1 we still do not deliver effective care, early in the course of illness, to most young people with anxiety, depression, or alcohol or other substance misuse.2 Even when we do deliver care, the longer term functional outcomes are often disappointing.3 The consequences of this failure remain large — personally, socially and economically.4


      • Brain and Mind Centre, University of Sydney, Sydney, NSW


      Correspondence: ian.hickie@sydney.edu.au
      Competing interests:

      Project Synergy (2014–2016) was commissioned by the Department of Health and conducted by the Young and Well Cooperative Research Centre in partnership with the University of Sydney's Brain and Mind Centre. The Department of Health has provided Project Synergy further funding of $30 million which has led to the development of InnoWell Pty Ltd, a joint venture between the University of Sydney and PricewaterhouseCoopers (Australia) (PwC). InnoWell has developed the InnoWell Platform, which is mentioned throughout the Supplement as a technology‐enabled solution to reform mental health care services. The University of Sydney and PwC (Australia) each have a 45% shareholding in InnoWell. The remaining 10% shareholding is evenly shared between Professor Jane Burns and Professor Ian Hickie.

      • 1. McGorry P, Goldstone S, Parker A, et al. Cultures for mental health care of young people: an Australian blueprint for reform. Lancet Psychiatry 2014; 1: 559–568.
      • 2. Australian Institute of Health and Welfare. Mental health services: in brief 2018. Canberra: AIHW; 2018. https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia-in-brief-2018/contents/table-of-contents (accessed Sep 2019).
      • 3. Iorfino F, Hermens D, Cross S, et al. Delineating the trajectories of social and occupational functioning of young people attending early intervention mental health services in Australia: a longitudinal study. BMJ Open 2018; 8. e020678.
      • 4. Patel V, Saxena S, Lund C, et al. The Lancet Commission on global mental health and sustainable development. Lancet 2018; 392: 1553–1598.
      • 5. Liberal Party of Australia. Our plan for youth mental health and suicide prevention. https://www.liberal.org.au/our-plan-youth-mental-health-and-suicide-prevention (accessed Sep 2019).
      • 6. Hickie IB, Scott EM, Cross SP, et al. Right care, first time: a highly personalised and measurement‐based care model to manage youth mental health. Med J Aust 2019; 211 (9 Suppl): S3–S46.
      • 7. Hickie IB, Davenport TA, Burns J. Project Synergy: co‐designing technology‐enabled solutions for Australian mental health services reform. Med J Aust 2019; 211 (7 Suppl): S3–S39. https://www.mja.com.au/journal/2019/211/7/project-synergy-co-designing-technology-enabled-solutions-australian-mental
      • 8. Lewis CC, Boyd M, Puspitasari A, et al. Implementing measurement‐based care in behavioral health: a review. JAMA Psychiatry 2019; 76: 324–335.
      • 9. Iorfino F, Hickie I, Lee R, et al. The underlying neurobiology of key functional domains in young people with mood and anxiety disorders: a systematic review. BMC Psychiatry 2016; 16: 156.
      • 10. McGorry P, Hickie I, Yung A, et al. Clinical staging of psychiatric disorders: a heuristic framework for choosing earlier, safer and more effective interventions. Aust N Z J Psychiatry 2006; 40: 616–622.
      • 11. McGorry PD, Purcell R, Hickie IB, et al. Clinical staging: a heuristic model for psychiatry and youth mental health. Med J Aust 2007; 187: S40. https://www.mja.com.au/journal/2007/187/7/clinical-staging-heuristic-model-psychiatry-and-youth-mental-health.
      • 12. McGorry P, Hickie I, editors. Clinical staging in psychiatry: making diagnosis work for research and treatment. Cambridge: Cambridge University Press, 2019.
      • 13. Iorfino F, Scott EM, Carpenter JS, et al. Clinical stage transitions in persons aged 12 to 25 years presenting to early intervention mental health services with anxiety, mood, and psychotic disorders. JAMA Psychiatry 2019; https://doi.org/10.1001/jamapsychiatry.2019.2360.
      • 14. McGorry PD, Ratheesh A, O'Donoghue B. Early intervention – an implementation challenge for 21st century mental health care. JAMA Psychiatry 2018; 75: 545–546.
      • 15. Couvy‐Duchesne B, O'Callaghan V, Parker R, et al. Nineteen and Up study (19Up): understanding pathways to mental health disorders in young Australian twins. BMJ Open. 2018; 8: e018959.
      • 16. Hickie I, Scott J, Hermens D, et al. Clinical classification in mental health at the cross‐roads: which direction next? BMC Med 2013; 11: 125.
      • 17. Chang L, Couvy‐Duchesne B, Medland S, et al. The genetic relationship between psychological distress, somatic distress, affective disorders, and substance use in young Australian adults: a multivariate twin study. Twin Res Hum Genet 2018; 21: 347–360.
      • 18. Hickie IB, Hermens DF, Naismith SL, et al. Evaluating differential developmental trajectories to adolescent‐onset mood and psychotic disorders. BMC Psychiatry 2013; 13: 303.
      • 19. Hickie IB, Banati R, Stewart CH, Lloyd AR. Are common childhood or adolescent infections risk factors for schizophrenia and other psychotic disorders? Med J Aust 2009; 190: S17–S21. https://www.mja.com.au/journal/2009/190/4/are-common-childhood-or-adolescent-infections-risk-factors-schizophrenia-and.
      • 20. Baune B, editor. Inflammation and immunity in depression: basic science and clinical applications. Academic Press, 2018.
      • 21. Weber D. Groundbreaking study links immune system to mental health. ABC News 2016; 27 May. https://www.abc.net.au/news/2016-05-27/mental-health-study-a-boon-to-patients-immune-system/7455310 (accessed Sep 2019).
      • 22. Australian Government Department of Health. The size, skill level and distribution of the workforce with mental health skills. September 2010. https://www1.health.gov.au/internet/publications/publishing.nsf/Content/mentalba-eval-c-toc~mental-ba-eval-c-4~mental-ba-eval-c-4-2 (accessed Sep 2019).
      • 23. Carbone S, Rickwood D, Tanti C. Workforce shortages and their impact on Australian youth mental health service reform. Adv Mental Health 2011; 10: 92–97.
      • 24. Page A, Atkinson J, Campos W, et al. A decision support tool to inform local suicide prevention activity in Greater Western Sydney (Australia). Aust N Z J Psychiatry 2018; 52: 983–993.
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        Extending the criteria for acceptable organ donors: balancing the risks

        Sakhee Kotecha and Trevor J Williams
        Med J Aust 2019; 211 (9): . || doi: 10.5694/mja2.50370
        Published online: 4 November 2019

        Understanding the low risk of blood‐borne virus infections in donors could help expand the pool of available organs

        Solid organ donation and transplantation rates in Australia have increased in recent years, but demand continues to exceed supply.1 Morbidity and mortality for people on the waiting list remain problems, and strategies to expand the donor pool include accepting donations after circulatory death and adopting extended criteria for acceptable donors.2


        • 1 Alfred Hospital, Melbourne, VIC
        • 2 Monash University, Melbourne, VIC


        Correspondence: t.williams@alfred.org.au
        Competing interests:

        No relevant disclosures.

        • 1. Australia and New Zealand Organ Donation Registry. Organ waiting list. https://www.anzdata.org.au/anzod/reports/organ-waiting-list (viewed June 2019).
        • 2. Rakhra SS, Opdam HI, Gladkis L, et al. Untapped potential in Australian hospitals for organ donation after circulatory death. Med J Aust 2017; 207: 294–301. https://www.mja.com.au/journal/2017/207/7/untapped-potential-australian-hospitals-organ-donation-after-circulatory-death
        • 3. Kucirka LM, Sarathy H, Govindan P, et al. Risk of window period HIV infection in high infectious risk donors: systematic review and meta‐analysis. Am J Transplant 2011; 11: 1176–1187.
        • 4. Kucirka LM, Sarathy H, Govindan P, et al. Risk of window period hepatitis‐C infection in high infectious risk donors: systematic review and meta‐analysis. Am J Transplant 2011; 11: 1188–1200.
        • 5. Waller KMJ, De La Mata NL, Kelly PJ, et al. Residual risk of infection with blood‐borne viruses in potential organ donors at increased risk of infection: systematic review and meta‐analysis. Med J Aust 2019; 211: 414–420.
        • 6. Australia and New Zealand Dialysis and Transplant Registry. Mortality in end stage kidney disease. In: ANZDATA 41st annual report (2018). Adelaide: ANZDATA, 2018. https://www.anzdata.org.au/wp-content/uploads/2018/11/c03_mortality_2017v1.0_20181122.pdf (viewed June 2019).
        • 7. Australia and New Zealand Liver Transplant Registry. 29th registry report 2017. Brisbane: ANZLTR, 2017. https://www3.anzltr.org/wp-content/uploads/Reports/29thReport.pdf (viewed June 2019).
        • 8. Australia and New Zealand Cardiothoracic Organ Transplant Registry. 2018 report. http://www.anzcotr.org.au/pub/e0cc941a/PDFS/ANZCOTR2018_text.pdf (viewed 24 June 2019).
        • 9. Günthard HF, Saag MS, Benson CA, et al. Antiretroviral drugs for treatment and prevention of HIV infection in adults. JAMA 2016; 316: 191–210.
        • 10. Defresne F, Sokal E. Chronic hepatitis B in children: therapeutic challenges and perspectives. J Gastroenterol Hepatol 2017; 32: 368–371.
        • 11. Liu SK, Seto WK, Lai CL, Yuen MF. Hepatitis B: treatment choice and monitoring for response and resistance. Expert Rev Gastroenterol Hepatol 2016; 10: 697–707.
        • 12. Vallet‐Pichard A, Fontaine H, Mallet V, Pol S. Viral hepatitis in solid organ transplantation other than liver. J Hepatol 2011; 55: 474–482.
        • 13. Mohanty SR, Cotler SJ. Management of hepatitis B in liver transplant patients. J Clin Gastroenterol 2005; 39: 58–63.
        • 14. D'Ambrosio R, Degasperi E, Colombo M, Aghemo A. Direct‐acting antivirals: the endgame for hepatitis C? Curr Opin Virol 2017; 24: 31–37.
        • 15. Goldberg DS, Abt PL, Reese PP; THINKER Trial Investigators. Transplanting HCV‐infected kidneys into uninfected recipients. N Engl J Med 2017; 377: 1105.
        • 16. Schlendorf KH, Zalawadiya S, Shah AS, et al. Early outcomes using hepatitis C‐positive donors for cardiac transplantation in the era of effective direct‐acting anti‐viral therapies. J Heart Lung Transplant 2018; 37: 763–769.
        • 17. Woolley AE, Singh SK, Goldberg HJ, et al; DONATE HCV Trial Team. Heart and lung transplants from HCV‐infected donors to uninfected recipients. N Engl J Med 2019; 380: 1606–1617.
        • 18. Snell GI, Westall GP, Oto T. Donor risk prediction: how “extended” is safe? Curr Opin Organ Transplant 2013; 18: 507–512.
        • 19. Eberlein M, Reed RM. Donor to recipient sizing in thoracic organ transplantation. World J Transplant 2016; 6: 155–164.
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          Nationally linked data to improve health services and policy

          Tom G Briffa, Louisa Jorm, Rodney T Jackson, Christopher Reid and Derek P Chew
          Med J Aust 2019; 211 (9): . || doi: 10.5694/mja2.50368
          Published online: 4 November 2019

          A well designed National Integrated Health Services Information Analysis Asset will improve services and policy

          New Zealand continues to set best practice standards internationally for cardiovascular disease (CVD) risk prediction and management. A 2018 study, using data from the PREDICT general practice cohort linked with demographic, prior medical history and drug‐dispensing data highlighted that the risk of CVD is best estimated from longitudinal follow‐up of a contemporary nationally representative cohort initially free of disease.1 PREDICT is a risk tool that incorporates new predictors of socio‐economic deprivation and ethnicity and better reflects the population whose risk is being assessed. In comparison, the application of earlier international risk equations to Australasian populations, such as the Pooled Cohort Risk Equations (PCEs)2 in the United States and QRISK in the United Kingdom,3 are likely to substantially underestimate or overestimate risk, leading to either undertreatment or overtreatment. Where underestimates of risk occur, the individual is falsely reassured and no indication to commence preventive treatment is apparent. The reverse is true for overestimates of risk, where an indication to start preventive treatment is unnecessary. This is particularly true among socially disadvantaged and ethnically diverse populations, where both PCEs and QRISK underperform. New Zealand's ability to integrate its administrative health datasets with other data sources — in this case, primary care — has enabled the conduct of this policy changing research. The New Zealand's Ministry of Health has adopted and supported the roll‐out of the updated CVD risk management guidelines recommending that general practitioners use the new PREDICT‐derived CVD risk equation. It is thus important that Australia has a national repository that enables the combination of routine health datasets with other data sources, existing and emerging, to permit evaluation of health care and inform policy decisions.


          • 1 University of Western Australia, Perth, WA
          • 2 Centre for Big Data Research in Health, UNSW Sydney, Sydney, NSW
          • 3 University of Auckland, Auckland, New Zealand
          • 4 Curtin University, Perth, WA
          • 5 Flinders University, Adelaide, SA


          Correspondence: tom.briffa@uwa.edu.au
          Competing interests:

          No relevant disclosures.

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            Pilot trial of digital breast tomosynthesis (3D mammography) for population‐based screening in BreastScreen Victoria

            Nehmat Houssami, Darren Lockie, Michelle Clemson, Vicki Pridmore, David Taylor, Georgina Marr, Jill Evans and Petra Macaskill
            Med J Aust 2019; 211 (8): . || doi: 10.5694/mja2.50320
            Published online: 21 October 2019

            Abstract

            Objectives: To estimate detection measures for tomosynthesis and standard mammography; to assess the feasibility of using tomosynthesis in population‐based screening for breast cancer.

            Design, setting: Prospective pilot trial comparing tomosynthesis (with synthesised 2D images) and standard mammography screening of women attending Maroondah BreastScreen, a BreastScreen Victoria service in the eastern suburbs of Melbourne.

            Participants: Women at least 40 years of age who presented for routine breast screening between 18 August 2017 and 8 November 2018.

            Main outcome measures: Cancer detection rate (CDR); proportion of screens that led to recall for further assessment.

            Results: 5018 tomosynthesis and 5166 standard mammography screens were undertaken in 10 146 women; 508 women (5.0% of screens) opted not to undergo tomosynthesis screening. With tomosynthesis, 49 cancers (40 invasive, 9 in situ) were detected (CDR, 9.8 [95% CI, 7.2–13] per 1000 screens); with standard mammography, 34 cancers (30 invasive, 4 in situ) were detected (CDR, 6.6 [95% CI, 4.6–9.2] per 1000 screens). The estimated difference in CDR was 3.2 more detections (95% CI, –0.32 to 6.8) per 1000 screens with tomosynthesis; the difference was greater for repeat screens and for women aged 60 years or more. The recall rate was greater for tomosynthesis (4.2%; 95% CI, 3.6–4.8%) than standard mammography (3.0%; 95% CI, 2.6–3.5%; estimated difference, 1.2%; 95% CI, 0.46–1.9%). The median screen reading time for tomosynthesis was 67 seconds (interquartile range [IQR] 46–105 seconds); for standard mammography, 16 seconds (IQR, 10–29 seconds).

            Conclusions: Breast cancer detection, recall for assessment, and screen reading time were each higher for tomosynthesis than for standard mammography. Our preliminary findings could form the basis of a large scale comparative evaluation of tomosynthesis and standard mammography for breast screening in Australia.

            Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12617000947303.

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            • 1 Sydney School of Public Health, University of Sydney, Sydney, NSW
            • 2 Eastern Health Breast and Cancer Centre, Melbourne, VIC
            • 3 BreastScreen Victoria, Melbourne, VIC
            • 4 Box Hill Hospital, Melbourne, VIC


            Acknowledgements: 

            The study was funded by a National Breast Cancer Foundation (NBCF) Australia pilot study grant. Nehmat Houssami is funded by an NBCF Breast Cancer Research Leadership Fellowship. We thank Sue Viney and John Heggie for important contributions to our study. We thank the radiology, radiography, data and administrative staff at Maroondah BreastScreen, and also thank the information technology staff, the client communications and recruitment team, and the data management staff at BreastScreen Victoria for helping us implement the trial. We thank the women who attended Maroondah BreastScreen and participated in the study.

            Competing interests:

            No relevant disclosures.

            • 1. Lauby‐Secretan B, Scoccianti C, Loomis D, et al; International Agency for Research on Cancer Handbook Working Group. Breast‐cancer screening: viewpoint of the IARC Working Group. N Engl J Med 2015; 372: 2353–2358.
            • 2. Nelson HD, Fu R, Cantor A, et al. Effectiveness of breast cancer screening: systematic review and meta‐analysis to update the 2009 US Preventive Services Task Force recommendation. Ann Int Med 2016; 164: 244–255.
            • 3. 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.
            • 4. Houssami N, Miglioretti DL. Digital breast tomosynthesis: a brave new world of mammography screening. JAMA Oncol 2016; 2: 725–727.
            • 5. Ciatto S, Houssami N, Bernardi D, et al. Integration of 3D digital mammography with tomosynthesis for population breast‐cancer screening (STORM): a prospective comparison study. Lancet Oncol 2013; 14: 583–589.
            • 6. Marinovich ML, Hunter KE, Macaskill P, Houssami N. Breast cancer screening using tomosynthesis or mammography: a meta‐analysis of cancer detection and recall. J Natl Cancer Inst 2018; 110: 942–949.
            • 7. Zackrisson S, Lång K, Rosso A, et al. One‐view breast tomosynthesis versus two‐view mammography in the Malmo Breast Tomosynthesis Screening Trial (MBTST): a prospective, population‐based, diagnostic accuracy study. Lancet Oncol 2018; 19: 1493–1503.
            • 8. Pattacini P, Nitrosi A, Giorgi Rossi P, et al; RETomo Working Group. Digital mammography versus digital mammography plus tomosynthesis for breast cancer screening: the Reggio Emilia tomosynthesis randomized trial. Radiology 2018; 288: 375–385.
            • 9. Australian Institute of Health and Welfare. BreastScreen Australia monitoring report 2014–2015 (Cat. No. CAN 105; Cancer series no. 106). Canberra: Australian Institute of Health and Welfare, 2017.
            • 10. Yun SJ, Ryu CW, Rhee SJ, et al. Benefit of adding digital breast tomosynthesis to digital mammography for breast cancer screening focused on cancer characteristics: a meta‐analysis. Breast Cancer Res Treat 2017; 164: 557–569.
            • 11. Bernardi D, Macaskill P, Pellegrini M, et al. Breast cancer screening with tomosynthesis (3D mammography) with acquired or synthetic 2D mammography compared with 2D mammography alone (STORM‐2): a population‐based prospective study. Lancet Oncol 2016; 17: 1105–1113.
            • 12. Houssami N, Lee CI. The impact of legislation mandating breast density notification: review of the evidence. Breast 2018; 42: 102–112.
            • 13. Bernardi D, Ciatto S, Pellegrini M, et al. Application of breast tomosynthesis in screening: incremental effect on mammography acquisition and reading time. Br J Radiol 2012; 85: e1174–e1178.
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              Including ethnic and cultural diversity in dementia research

              Lee‐Fay Low, Annica L Barcenilla‐Wong and Bianca Brijnath
              Med J Aust 2019; 211 (8): . || doi: 10.5694/mja2.50353
              Published online: 21 October 2019

              Australian dementia research needs increased representation of people from culturally and linguistically diverse backgrounds

              Evidence‐based practice and policy must be based on the best available evidence, which should be representative of the population.1 However, the current body of dementia research does not reflect the ethnic and cultural diversity of the Australian population. Hence, people from culturally and linguistically diverse (CALD) backgrounds may receive inequitable dementia care as there is less evidence to help optimise clinical and service decisions.


              • 1 University of Sydney, Sydney, NSW
              • 2 National Ageing Research Institute, Melbourne, VIC
              • 3 Monash University, Melbourne, VIC


              Acknowledgements: 

              The data presented in this article were funded by the NNIDR as part of the development of the CALD Dementia Research Roadmap. Lee‐Fay Low is funded through an NHMRC Boosting Dementia Research Leadership Development Fellowship. The NNIDR were involved in conceptualising the article, but not in analysis or interpretation.

              Competing interests:

              Bianca Brijnath has financial relationships with government and private foundations for research and policy development specific to CALD communities and dementia.

              • 1. Djulbegovic B, Guyatt GH. Progress in evidence‐based medicine: a quarter century on. Lancet 2017; 390: 415–423.
              • 2. Babulal GM, Quiroz YT, Albensi BC, et al. Perspectives on ethnic and racial disparities in Alzheimer's disease and related dementias: Update and areas of immediate need. Alzheimers Dement 2018; 15: 292–312.
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              • 8. Alzheimer's Australia Vic. Perceptions of dementia in ethnic communities. Melbourne: Alzheimer's Australia Vic, 2008. https://www.dementia.org.au/files/20101201-Nat-CALD-Perceptions-of-dementia-in-ethnic-communities-Oct08.pdf (viewed Sept 2019).
              • 9. Aoun SM, Toye C, Slatyer S, et al. A person‐centred approach to family carer needs assessment and support in dementia community care in Western Australia. Health Soc Care Community 2018; 26: e578–e586.
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              • 16. Australian Institute of Health and Welfare. Dementia in Australia (Cat. No. AGE 70). Canberra: AIHW, 2012. https://www.aihw.gov.au/getmedia/199796bc-34bf-4c49-a046-7e83c24968f1/13995.pdf.aspx?inline=true (viewed Sept 2019).
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              • 19. NHMRC National Institute for Dementia Research (NNIDR). Australia's Boosting Dementia Research Initiative: report on early outcomes. Canberra: Commonwealth of Australia, 2018. https://www.nnidr.gov.au/sites/default/files/files/Boosting%20Dementia%20Research%20Initiative%20Early%20Outcomes%20Report.PDF (viewed Sept 2019).
              • 20. Ellis KA, Ai Bush, Darby D, et al. The Australian Imaging, Biomarkers and Lifestyle (AIBL) study of aging: methodology and baseline characteristics of 1112 individuals recruited for a longitudinal study of Alzheimer's disease. Int Psychogeriatr 2009; 21: 672–687.
              • 21. Heffernan M, Andrews F, Fiatarone Singh MA, et al. Maintain your brain: protocol of a 3‐year randomized controlled trial of a personalized multi‐modal digital health intervention to prevent cognitive decline among community dwelling 55 to 77 year olds. J Alzheimers Dis 2019; 70: S221–S237.
              • 22. Dementia Australia. Australian Dementia Network (ADNeT) Registry and Clinical Trials Program [website]. Dementia Australia, 2018. https://www.dementia.org.au/news/2018/australian-dementia-network-adnet-registry-and-clinical-trials-program (viewed Feb 2019).
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              • 30. Brewster P, Barnes L, Haan M, et al. Progress and future challenges in aging and diversity research in the United States. Alzheimers Dement 2019; 15: 995–1003.
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                Responding to mandatory immigration detention: lessons for the health care community

                Ryan Essex and David Isaacs
                Med J Aust 2019; 211 (9): . || doi: 10.5694/mja2.50366
                Published online: 14 October 2019

                After 25 years of advocacy, what can the health care community learn from recent reforms of Australian immigration detention?

                In February 2019, the Australian Government announced that it had removed all refugee and asylum seeker children from offshore detention in Nauru.1 Soon after, the Australian Parliament passed the Migration Amendment (Urgent Medical Treatment) Bill 2018.2 This legislation strengthens the position of doctors to recommend a transfer of an ill person to Australia for treatment from offshore detention centres in Manus Island (Papua New Guinea) and Nauru. While this has been welcome news, these developments are tempered by the fact that the government is seeking to repeal this legislation and has maintained an increasingly combative stance on these issues.


                • 1 University of Sydney, Sydney, NSW
                • 2 University of Greenwich, London, UK
                • 3 Barts Health NHS Trust, London, UK
                • 4 Children's Hospital at Westmead, Sydney, NSW


                Correspondence: r.w.essex@gre.ac.uk
                Competing interests:

                No relevant disclosures.

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                  Frailty in very old critically ill patients in Australia and New Zealand: a population‐based cohort study

                  Jai N Darvall, Rinaldo Bellomo, Eldho Paul, Ashwin Subramaniam, John D Santamaria, Sean M Bagshaw, Sumeet Rai, Ruth E Hubbard and David Pilcher
                  Med J Aust 2019; 211 (7): . || doi: 10.5694/mja2.50329
                  Published online: 7 October 2019

                  Abstract

                  Objective: To explore associations between frailty (Clinical Frailty Scale score of 5 or more) in very old patients in intensive care units (ICUs) and their clinical outcomes (mortality, discharge destination).

                  Design, setting and participants: Retrospective population cohort analysis of Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database data for all patients aged 80 years or more admitted to participating ICUs between 1 January 2017 and 31 December 2018.

                  Main outcome measures: Primary outcome: in‐hospital mortality; secondary outcomes: length of stay (hospital, ICU), re‐admission to ICU during the same hospital admission, discharge destination (including new chronic care or nursing home admission).

                  Results: Frailty status data were available for 15 613 of 45 773 patients aged 80 years or more admitted to 178 ICUs (34%); 6203 of these patients (39.7%) were deemed frail. A smaller proportion of frail than non‐frail patients were men (47% v 57%), the mean illness severity scores of frail patients were slightly higher than those of non‐frail patients, and they were more frequently admitted from the emergency department (28% v 21%) or with sepsis (12% v 7%) or respiratory complications (16% v 12%). In‐hospital mortality was higher for frail patients (17.6% v 8.2%; adjusted odds ratio [OR], 1.87 [95% CI, 1.65–2.11]). Median lengths of ICU and hospital stay were slightly longer for frail patients, and they were more frequently discharged to new nursing home or chronic care (4.9% v 2.8%; adjusted OR, 1.61 [95% CI, 1.34–1.95]).

                  Conclusions: Many very old critically ill patients in Australia and New Zealand are frail, and frailty is associated with considerably poorer health outcomes. Routine screening of older ICU patients for frailty could improve outcome prediction and inform intensive care and community health care planning.

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                  • 1 Royal Melbourne Hospital, Melbourne, VIC
                  • 2 Centre for Integrated Critical Care, University of Melbourne, Melbourne, VIC
                  • 3 Austin Hospital, Melbourne, VIC
                  • 4 Monash University, Melbourne, VIC
                  • 5 Peninsula Health, Melbourne, VIC
                  • 6 Peninsula Clinical School, Monash University, Melbourne, VIC
                  • 7 St Vincent's Hospital Melbourne, Melbourne, VIC
                  • 8 University of Alberta, Edmonton, AB, Canada
                  • 9 ANU Medical School, Australian National University, Canberra, ACT
                  • 10 Canberra Hospital, Canberra, ACT
                  • 11 Centre for Health Services Research, University of Queensland, Brisbane, QLD
                  • 12 The Alfred Hospital, Melbourne, VIC
                  • 13 Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC


                  Correspondence: jai.darvall@mh.org.au
                  Acknowledgements: 

                  Sean Bagshaw is supported by a Canada Research Chair in Critical Care Nephrology.

                  Competing interests:

                  No relevant disclosures.

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                    Difficulties in knowing which critical care trial data warrant change in practice

                    Benjamin Reddi, Mark Finnis and Sandra Peake
                    Med J Aust 2019; 211 (7): . || doi: 10.5694/mja2.50331
                    Published online: 7 October 2019

                    Why is some strong evidence ignored while some weak evidence is rapidly acted upon?

                    Most clinicians aspire to practise evidence‐based medicine, no longer believing it acceptable to implement novel interventions simply because they “make sense” or remain untested. However, external influences, psychological factors, and misapplied statistical techniques may hinder rational decision making. Using examples from intensive care literature, we discuss why well supported therapies are not always readily adopted, while poorly supported interventions may be unduly welcomed into practice.


                    • 1 Royal Adelaide Hospital, Adelaide, SA
                    • 2 Queen Elizabeth Hospital, Adelaide, SA


                    Correspondence: Benjamin.Reddi@sa.gov.au
                    Competing interests:

                    No relevant disclosures.

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                      Towards gender balance in the Australian intensive care medicine workforce

                      Lucy J Modra and Sarah A Yong
                      Med J Aust 2019; 211 (7): . || doi: 10.5694/mja2.50330
                      Published online: 7 October 2019

                      Achieving gender equity in intensive care medicine requires specific interventions to attract and retain female trainees and support their progress to leadership roles

                      For several decades, women have comprised about half of medical graduates in Australia.1 This is yet to translate into a gender‐balanced specialty workforce. In 2016, fewer than one in five practising surgeons, cardiologists and intensivists were women.2 In recognition of this, several Colleges have developed plans to improve gender balance within their specialty.


                      • 1 Austin Health, Melbourne, VIC
                      • 2 Alfred Health, Melbourne, VIC
                      • 3 Monash University, Melbourne, VIC


                      Correspondence: Lucy.MODRA@austin.org.au
                      Competing interests:

                      Lucy Modra and Sarah Yong are founding convenors of the WIN‐ANZICS Committee.

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