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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.
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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.
Bianca Brijnath has financial relationships with government and private foundations for research and policy development specific to CALD communities and dementia.
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.
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No relevant disclosures.
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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Sean Bagshaw is supported by a Canada Research Chair in Critical Care Nephrology.
No relevant disclosures.
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.
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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.
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Lucy Modra and Sarah Yong are founding convenors of the WIN‐ANZICS Committee.
The similarity in mortality among Indigenous and non‐Indigenous critically ill patients hides a complex story
Aboriginal and Torres Strait Islander Australians are more likely to be admitted to acute care hospitals than non‐Indigenous Australians.1 While this is widely recognised, the over‐representation of Indigenous patients in Australian intensive care units (ICUs) has been highlighted only recently.2,3 The headline finding that Indigenous Australians have an ICU admission rate that is 1.2 times the expected rate considering population representation is concerning, although not surprising, given higher Indigenous hospitalisation rates.1,2,3 It is reassuring that Indigenous patients appear to have similar in‐ICU and in‐hospital mortality.2,3 Intensivists should be justifiably proud of this mortality equivalence, but deeper analysis conveys some inconvenient truths.
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Despite the evolving needs of patients and changing societal expectations, Australasian intensive care continues to provide a world leading service to patients and the broader society
With Melbourne hosting the 2019 World Congress of Intensive Care, it is timely to reflect on the nature of the speciality and consider its role within health care. The intensive care unit (ICU) can be a daunting place. For patients, families and even non‐intensive care clinicians, the complex and technically advanced environment can feel intimidating. The ICU represents a microcosm of the broader acute health care system, where the challenges of patient‐centred care, treatment, communication and resource management are encountered in a more impactful setting. The reach of intensive care is wide; current estimates from the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation suggest that Australians and New Zealanders have a 50% lifetime chance of requiring admission to an ICU.1 Intensive care interacts with every other element of acute care, serving the needs of patients, specialist units, hospitals and broader society. In its more recent history, intensive care has evolved to encompass more than just a single geographic location; it is an organised system of care that ensures delivery of timely and expert treatment to critically ill patients, increasingly extending this capability beyond the walls of the ICU itself and into many other settings.
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Stephen Warrilow is President of the Australian and New Zealand Intensive Care Society and Convenor of the 2019 World Congress of Intensive Care. Raymond Raper is President of the CICM.
Sports participation by children and adolescents is generally high in Australia and New Zealand,1,2 and many children sustain head injuries of varying severity during such activities. Concussion has received increasing attention, but less is known about the risk of severe acute intracranial injuries in children with sports‐related head injuries.3
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The study was funded by grants from the National Health and Medical Research Council (NHMRC; project grant GNT1046727, Centre of Research Excellence for Paediatric Emergency Medicine GNT1058560); the Murdoch Children's Research Institute, Melbourne; the Emergency Medicine Foundation, Brisbane (EMPJ‐11162); Perpetual Philanthropic Services (2012/1140); Auckland Medical Research Foundation (3112011) and the A + Trust (Auckland District Health Board); WA Health Targeted Research Funds 2013; and the Townsville Hospital and Health Service Private Practice Research and Education Trust Fund; and was supported by the Victorian Government Infrastructure Support Program. Franz Babl was partly funded by an NHMRC Practitioner Fellowship and a Melbourne Campus Clinician Scientist fellowship. Stuart Dalziel was partly funded by the Health Research Council of New Zealand (HRC13/556).
No relevant disclosures.
Many Australians living in rural and remote areas of Australia need to travel hundreds of kilometres for health care service, or to wait for health service providers, such as the Royal Flying Doctor Service (RFDS), to visit them. The levels of acute and subacute hospital services in rural and remote areas are reported to be inadequate,1 as is, to a lesser extent, access to aged care services.2 The need to travel long distances is a major barrier for people in remote locations, particularly older people, seeking health care.
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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.