Topics

Digestive system diseases

Women's health

Summary

The best pregnancy outcomes for women with inflammatory bowel disease (IBD) occur when their disease is in remission at conception and remains in remission throughout pregnancy.
Active IBD can lead to adverse pregnancy outcomes, including spontaneous abortion, pre‐term birth and low birthweight.
The majority of women with IBD who are taking maintenance medication will require medication throughout the pregnancy to prevent disease relapse.
Most IBD medications are considered safe in pregnancy and breastfeeding, except for methotrexate.
Pre‐conception counselling should be arranged with the patient's IBD specialist and should include discussions regarding the importance of optimising disease control before and during pregnancy as well as the medication management plan for pregnancy.
Patients with IBD should be reassured that their fertility is normal when the disease is quiescent, with the exception of women who have had pelvic surgery.
IBD activity should be carefully monitored during pregnancy using non‐invasive techniques, and disease flares during pregnancy should be treated promptly with escalation of therapy in consultation with the patient's IBD specialist.
Mode of delivery should be determined by obstetric need; however, caesarean delivery is preferred for women with a history of ileal pouch anal anastomosis surgery or active perianal Crohn's disease.

St Vincent's Hospital, Melbourne, VIC

Correspondence: Sally.Bell@svhm.org.au

Competing interests:

No relevant disclosures.

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Research

Evaluating the benefits of a rapid access chest pain clinic in Australia

James Andrew Black, Kevin Cheng, Jo‐Anne Flood, Garry Hamilton, Serena Parker, Anees Enayati, Faisal S Khan and Tom Marwick

Med J Aust 2019; 210 (7): . || doi: 10.5694/mja2.50021
Published online: 25 March 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Cardiovascular diseases

General medicine

Diagnostic techniques and procedures

Abstract

Objectives: To compare the outcomes and safety of a rapid access chest pain clinic (RACPC) in Australia with those of a general cardiology clinic.

Design: Prospective comparison of the outcomes for patients attending an RACPC and those of historical controls.

Setting: Royal Hobart Hospital cardiology outpatient department.

Participants: 1914 patients referred for outpatient evaluation of new onset chest pain (1479 patients seen in the RACPC, 435 patients previously seen in the general cardiology clinic).

Main outcome measures: Service outcomes (review times, number of clinic reviews); adverse events (unplanned emergency department re‐attendances at 30 days and 12 months; major adverse cardiovascular events at 12 months, including unplanned revascularisation, acute coronary syndrome, stroke, cardiac death).

Results: Median time to review was shorter for RACPC than for usual care patients (12 days [IQR, 8–15 days] v 45 days [IQR, 27–89 days]). All patients seen in the RACPC received a diagnosis at the first clinic visit, but only 139 patients in the usual care group (32.0%). There were fewer unplanned emergency department re‐attendances for patients in the RACPC group at 30 days (1.6% v 4.4%) and 12 months (5.7% v 12.9%) than in the control group. Major adverse cardiovascular events were less frequent among patients evaluated in the RACPC (0.2% v 1.4%).

Conclusions: Patients were evaluated more efficiently in the RACPC than in a traditional cardiology clinic, and their subsequent rates of emergency department re‐attendances and adverse cardiovascular events were lower.

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1 Royal Hobart Hospital, Hobart, TAS
2 Austin Health, Melbourne, VIC
3 Baker IDI Heart and Diabetes Institute, Melbourne, VIC

Correspondence: andrew.black@ths.tas.gov.au

Acknowledgements:

We gratefully acknowledge grants from the Tasmanian Community Fund and the virtual Tasmanian Academic Health Sciences Precinct. We thank the staff and patients of the Royal Hobart Hospital who attended or worked in the RACPC, as well as the National Heart Foundation for their ongoing support. We are grateful to James Sharman for his assistance with the statistical analyses.

Competing interests:

No relevant disclosures.

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10. Klimis H, Thiagalingam A, Altman M, et al. Rapid‐access cardiology services: can these reduce the burden of acute chest pain on Australian and New Zealand health services? Int Med J 2017; 47: 986–991.
11. Yu C, Sheriff MJ, Ng ACC, et al. A rapid access chest pain clinic (RACPC): initial Australian experience. Heart Lung Circ 2017; 27: 1376–1380.
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Research

Cultural respect in general practice: a cluster randomised controlled trial

Siaw‐Teng Liaw, Vicki Wade, John S Furler, Iqbal Hasan, Phyllis Lau, Margaret Kelaher, Wei Xuan and Mark F Harris

Med J Aust 2019; 210 (6): . || doi: 10.5694/mja2.50031
Published online: 25 March 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Health services administration

Indigenous health

Global health

General medicine

Abstract

Objective: To examine whether the Ways of Thinking and Ways of Doing (WoTWoD) cultural respect framework improves clinically appropriate anticipatory care in general practice and the cultural respect levels of medical practice staff.

Design: Mixed methods, cluster randomised controlled trial with a participatory action research approach.

Setting, participants: Fifty‐six general practices in Sydney and Melbourne, 2014–2017.

Intervention: WoTWoD encompasses a toolkit (ten scenarios illustrating cross‐cultural behaviour in clinical practice), one half‐day workshop, cultural mentor support for practices, and a local care partnership between participating Medicare locals/primary health networks and local Aboriginal Community Controlled Health Services for guiding the program and facilitating community engagement. The intervention lasted 12 months at each practice.

Major outcomes: Rates of claims for MBS item 715 (health assessment for Aboriginal and Torres Strait Islander People) and recording of chronic disease risk factors; changes in cultural quotient (CQ) scores of practice staff.

Results: Complete results were available for 28 intervention (135 GPs, 807 Indigenous patients) and 25 control practices (210 GPs, 1554 Indigenous patients). 12‐Month rates of MBS item 715 claims and recording of risk factors for the two groups were not statistically significantly different, nor were mean changes in CQ scores, regardless of staff category and practice attributes.

Conclusion: The WoTWoD program did not increase the rate of Indigenous health checks or improve cultural respect scores in general practice. Conceptual, methodologic, and contextual factors that influence cultural mentorship, culturally respectful clinical practice, and Indigenous health care require further investigation.

Trial registration: Australia New Zealand Clinical Trials Registry ACTRN12614000797673.

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1 UNSW Sydney, Sydney, NSW
2 Centre for Primary Health Care and Equity, UNSW Sydney, Sydney, NSW
3 Menzies School of Health Research, Darwin, NT
4 University of Melbourne, Melbourne, VIC
5 Centre for Health Policy, University of Melbourne, Melbourne, VIC
6 Ingham Institute of Applied Medical Research, Sydney, NSW

Correspondence: siaw@unsw.edu.au

Acknowledgements:

We acknowledge the contributions of Lisa Jackson‐Pulver and the cultural mentors Phillip Orcher, Faye Daniels, Rhonda McPherson, Aunty Diane Kerr, and Nina Fitzgerald that ensured the cultural appropriateness of the design, implementation and interpretation of our study. The trial was funded by the National Health and Medical Research Council (APP1065491).

Competing interests:

No relevant disclosures.

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2. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander health performance framework report 2008: detailed analyses. Canberra: AIHW, 2009.
3. Department of the Prime Minister and Cabinet (Australia). Closing the Gap: Prime Minister's report 2018. https://closingthegap.pmc.gov.au/sites/default/files/ctg-report-2018.pdf (viewed Dec 2018).
4. KPMG. National monitoring and evaluation of the Indigenous Chronic Disease Package: first monitoring report 2010–11. Canberra: Department of Health (Australia), 2013. http://www.health.gov.au/internet/main/publishing.nsf/Content/icdp-baseline-report (viewed Dec 2018).
5. Menzies School of Health Research. Sentinel sites evaluation: final report, February 2013. http://www.health.gov.au/internet/main/publishing.nsf/Content/icdp-sentinel-sites-project (viewed Dec 2018).
6. Department of Health (Australia). Aboriginal and Torres Strait Islander people. Information on health assessments and follow‐up allied health services. Updated Apr 2015. http://www.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycare_ATSI_mbsha_resource_kit (viewed Dec 2018).
7. Australian Institute of Health and Welfare. Indigenous health check (MBS 715) data tool (Cat. No. WEB 63). Updated 6 Dec 2017. https://www.aihw.gov.au/getmedia/b25f8967-8aa8-4382-9507-d28b9fc4a090/aihw-indigenous-healthcheck-tool-data-tables-2017.xls.aspx (viewed Dec 2018).
8. Australian Institute of Health and Welfare. Healthy futures — Aboriginal Community Controlled Health Services: report card 2016 (Cat No. IHW 171). Canberra: AIHW, 2016.
9. Australian Bureau of Statistics. Australian demographic statistics, June quarter 2016. 15 Dec 2016. http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&31010_jun%202016.pdf&3101.0&Publication&6DAF7F7C4A59465DCA25808900122564&&Jun%202016&15.12.2016&Latest.pdf (viewed Dec 2018).
10. Kendall E, Marshall CA. Factors that prevent equitable access to rehabilitation for Aboriginal Australians with disabilities: the need for culturally safe rehabilitation. Rehabilitation Psychology 2004; 49: 5–13.
11. McGrath P, Holewa H, Kail‐Buckley S. “They should come out here”: research findings on lack of local palliative care services for Australian Aboriginal people. Am J Hosp Palliat Care 2007; 24: 105–113.
12. Kelaher MA, Ferdinand AS, Paradies Y. Experiencing racism in health care: the mental health impacts for Victorian Aboriginal communities. Med J Aust 2014; 201: 44–47. https://www.mja.com.au/journal/2014/201/1/experiencing-racism-health-care-mental-health-impacts-victorian-aboriginal
13. Liaw S, Lau P, Pyett P, et al. Successful chronic disease care for Aboriginal Australians requires cultural competence. Aust N Z J Public Health 2011; 35: 238–248.
14. Downing R, Kowal E. A postcolonial analysis of Indigenous cultural awareness training for health workers. Health Soc Rev 2012; 20: 5–15.
15. Liaw S, Hasan I, Wade V, et al. Improving cultural respect to improve Aboriginal health in general practice: a multi‐methods and multi‐perspective pragmatic study. Aust Fam Physician 2015; 44: 387–392.
16. Australian Health Ministers’ Advisory Council Standing Committee on Aboriginal and Torres Strait Islander Health Working Party. AHMAC cultural respect framework for Aboriginal and Torres Strait Islander health, 2004–2009. Adelaide: Department of Health, South Australia, 2004. http://iaha.com.au/wp-content/uploads/2013/03/000211_culturalrespectframework.pdf (viewed Dec 2018).
17. Carson B, Dunbar T, Chenhall R, Bailie R. Social determinants of Indigenous health. Sydney: Allen and Unwin, 2007.
18. Couzos S, Thiele D. The International Covenant on Economic, Social and Cultural Rights and the right to health: is Australia meeting its obligations to Aboriginal peoples? Med J Aust 2007; 186: 522–524. https://www.mja.com.au/journal/2007/186/10/international-covenant-economic-social-and-cultural-rights-and-right-health
19. Australian Government. Statistics, boundary and concordance files. Oct 2013. Archived: https://web.archive.org/web/20140226184705/http://www.medicarelocals.gov.au/internet/medicarelocals/publishing.nsf/Content/digital-boundaries (viewed Dec 2018).
20. Department of Health (Australia). PHN background. Updated 19 July 2018. http://www.health.gov.au/internet/main/publishing.nsf/Content/PHN-Background (viewed Dec 2018).
21. Horner S, Rew L, Torres R. Enhancing intervention fidelity: a means of strengthening study impact. J Spec Pediatr Nurs 2006; 11: 80–89.
22. Ang S, Van Dyne L. Handbook of cultural intelligence: theory, measurement and applications. New York (NY): ME Sharpe, 2008.
23. Liaw ST, Wade V, Lau P, et al. Safe and effective cultural mentorship in general practice. Aust Fam Physician 2016; 45: 431–436.
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Research

Early initiation of antiretroviral therapy for people newly diagnosed with HIV infection in Australia: trends and predictors, 2004–2015

Hamish McManus, Denton Callander, Basil Donovan, Darren B Russell, Catherine C O'Connor, Stephen C Davies, David A Lewis, Margaret E Hellard, Marcus Y Chen, Kathy Petoumenos, Rick Varma, Aaron Cogle, Mark Alastair Boyd, Andrew Grulich, James Pollard, Nick Medland, Christopher K Fairley and Rebecca J Guy

Med J Aust 2019; 210 (6): . || doi: 10.5694/mja2.50006
Published online: 25 March 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Environment and public health

Immune system diseases

Abstract

Objectives: To determine trends in and predictors of early treatment for people newly diagnosed with human immunodeficiency virus (HIV) infection in Australia.

Design, setting: Retrospective cohort analysis of routinely collected longitudinal data from 44 sexual health clinics participating in the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance (ACCESS) program.

Participants: Patients diagnosed with HIV infections, January 2004 – June 2015.

Main outcome measures: Commencement of antiretroviral therapy within 6 months of HIV diagnosis (early treatment); demographic, clinical, and risk group characteristics of patients associated with early treatment; trends in early treatment, by CD4⁺ cell count at diagnosis.

Results: 917 people were diagnosed with HIV infections, their median age was 34 years (interquartile range [IQR]: 27–43 years), and 841 (92%) were men; the median CD4⁺ cell count at diagnosis was 510 cells/μL (IQR, 350–674 cells/μL). The proportion of patients who received early treatment increased from 17% (15 patients) in 2004–06 to 20% (34 patients) in 2007–09, 34% (95 patients) in 2010–12, and 53% (197 patients) in 2013–15 (trend, P < 0.001). The probability of early treatment, which increased with time, was higher for patients with lower CD4⁺ cell counts and higher viral loads at diagnosis.

Conclusions: The proportion of people newly diagnosed with HIV in sexual health clinics in Australia who received treatment within 6 months of diagnosis increased from 17% to 53% during 2004–2015, reflecting changes in the CD4⁺ cell count threshold in treatment guidelines. Nevertheless, further strategies are needed to maximise the benefits of treatment to prevent viral transmission and morbidity.

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1 The Kirby Institute, University of New South Wales, Sydney, NSW
2 Sydney Sexual Health Centre, Sydney Hospital, Sydney, NSW
3 Sexual Health Service Cairns, Cairns, QLD
4 Northern Sydney Sexual Health Service, Royal North Shore Hospital, Sydney, NSW
5 Western Sydney Sexual Health Centre, University of Sydney, Sydney
6 Centre for Population Health, Burnet Institute, Melbourne, VIC
7 Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC
8 Sydney Sexual Health Centre, South Eastern Sydney Local Health District, Sydney, NSW
9 National Association of People with HIV Australia, Melbourne, NSW
10 University of Adelaide, Adelaide, SA
11 Lyell McEwin Hospital, Adelaide, SA
12 University Hospital, Geelong, VIC
13 Melbourne Sexual Health Centre, Monash University Central Clinical School, Melbourne, VIC

Correspondence: hmcmanus@kirby.unsw.edu.au

Competing interests:

No relevant disclosures.

1. UNAIDS. 2016 United Nations political declaration on ending AIDS sets world on the fast‐track to end of the epidemic by 2030 [media release]. 8 June 2016. http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2016/june/20160608_PS_HLM_PoliticalDeclaration (viewed June 2017).
2. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV‐1 infection with early antiretroviral therapy. N Engl J Med 2011; 365: 493–505.
3. Bavinton BR, Jin F, Prestage G, et al. The Opposites Attract Study of viral load, HIV treatment and HIV transmission in serodiscordant homosexual male couples: design and methods. BMC Public Health 2014; 14: 917.
4. Das M, Chu PL, Santos GM, et al. Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco. PLoS One 2010; 5: e11068.
5. INSIGHT START Study Group; Lundgren JD, Babiker AG, Gordin F, et al. Initiation of antiretroviral therapy in early asymptomatic HIV infection. N Engl J Med 2015; 373: 795–807.
6. Australasian Society for HIV Medicine. HIV management in Australasia: a guide for clinical care. 2016. http://hivmanagement.ashm.org.au (viewed June 2017).
7. NSW Ministry of Health. NSW HIV strategy 2016–2020: quarter 4 and annual 2016 data report (NSW HIV Surveillance Data Reports). 2017. https://www.health.nsw.gov.au/endinghiv/Publications/q4-2016-annual-hiv-data-report.pdf (viewed June 2017).
8. DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV‐1‐infected adults and adolescents. Oct 2006. Washington (DC): Department of Health and Human Services, 2006. https://aidsinfo.nih.gov/contentfiles/adultandadolescentgl000629.pdf (viewed June 2017).
9. DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV‐1‐infected adults and adolescents. Dec 2007. Washington (DC): Department of Health and Human Services, 2007. http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL000721.pdf (viewed June 2017).
10. DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV‐1‐infected adults and adolescents. Dec 2009. Washington (DC): Department of Health and Human Services, 2009. https://aidsinfo.nih.gov/contentfiles/adultandadolescentgl001561.pdf (viewed June 2017).
11. Medland NA, McMahon JH, Chow EP, et al. The HIV care cascade: a systematic review of data sources, methodology and comparability. J Int AIDS Soc 2015; 18: 20634.
12. The Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia. Annual surveillance report 2016. Sydney: The Kirby Institute; UNSW Sydney, 2016. https://kirby.unsw.edu.au/report/annual-surveillance-report-hiv-viral-hepatitis-stis-2016 (viewed June 2017).
13. Medland NA, Chow EPF, McMahon JH, et al. Time from HIV diagnosis to commencement of antiretroviral therapy as an indicator to supplement the HIV cascade: dramatic fall from 2011 to 2015. PLoS One 2017; 12: e0177634.
14. Grulich AE, de Visser RO, Badcock PB, et al. Knowledge about and experience of sexually transmissible infections in a representative sample of adults: the Second Australian Study of Health and Relationships. Sex Health 2014; 11: 481–494.
15. Mao L, Holt M, Newman C, Treloar C. Annual report of trends in behaviour 2017: HIV and STIs in Australia. Sydney: Centre for Social Research in Health; UNSW Sydney, 2017. https://doi.org/10.4225/53/59faa5c891779 (viewed June 2018).
16. Callander D, Watchers‐Smith L, Moriera C, et al. The Australian Collaboration for Coordinated Enhanced Sentinel Surveillance of Sexually Transmissible Infections and Blood Borne Viruses. NSW HIV report 2007–2014. Sydney: UNSW Australia. https://kirby.unsw.edu.au/report/access-nsw-hiv-report-2007-2014 (viewed June 2017).
17. Callander D, Moreira C, El‐Hayek C, et al. Monitoring the control of sexually transmissible infections and blood‐borne viruses: protocol for the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance (ACCESS). JMIR Res Protoc 2018; 7: e11028.
18. Australasian Chapter of Sexual Health Medicine; Royal Australasian College of Physicians. Register of public sexual health clinics in Australia and New Zealand. Sydney: RACP, 2016. https://www.racp.edu.au/docs/default-source/default-document-library/register-of-public-sexual-health-clinics.pdf?sfvrsn=e64a2d1a_10 (viewed June 2018).
19. Aberg JA, Gallant JE, Ghanem KG, et al. Primary care guidelines for the management of persons infected with HIV: 2013 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2014; 58: 1–10.
20. Australian Bureau of Statistics. 1270.0.55.006. Australian Statistical Geography Standard (ASGS): correspondences, July 2011: postcode 2012 to remoteness area 2011. June 2012. http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/1270.0.55.006July%202011?OpenDocument (viewed June 2017).
21. Templeton DJ, Read P, Varma R, Bourne C. Australian sexually transmissible infection and HIV testing guidelines for asymptomatic men who have sex with men 2014: a review of the evidence. Sex Health 2014; 11: 217–229.
22. Cuzick J. A Wilcoxon‐type test for trend. Stat Med 1985; 4: 87–90.
23. Australasian Society for HIV Medicine. When to start antiretroviral therapy in people with HIV. Aug 2015; updated Oct 2017. http://arv.ashm.org.au/clinical-guidance (viewed June 2018).
24. DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV‐1‐infected adults and adolescents. Jan 2016. Washington (DC): Department of Health and Human Services, 2016. https://aidsinfo.nih.gov/contentfiles/adultandadolescentgl003412.pdf (viewed June 2017).
25. Petoumenos K, Watson J, Whittaker B, et al. Subsidized optimal ART for HIV‐positive temporary residents of Australia improves virological outcomes: results from the Australian HIV Observational Database Temporary Residents Access Study. J Int AIDS Soc 2015; 18: 19392.
26. Mocroft A, Lundgren JD, Sabin ML, et al. Risk factors and outcomes for late presentation for HIV‐positive persons in Europe: results from the Collaboration of Observational HIV Epidemiological Research Europe Study (COHERE). PLoS Med 2013; 10: e1001510.
27. Grierson J, Koelmeyer RL, Smith A, Pitts M. Adherence to antiretroviral therapy: factors independently associated with reported difficulty taking antiretroviral therapy in a national sample of HIV‐positive Australians. HIV Med 2011; 12: 562–569.
28. McMahon JH, Moore R, Eu B, et al. Clinic network collaboration and patient tracing to maximize retention in HIV care. PLoS One 2015; 10: e0127726.

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Perspectives

Monitoring the missing half: why reporting adolescent births is insufficient

Jennifer L Marino and Susan M Sawyer

Med J Aust 2019; 210 (5): . || doi: 10.5694/mja2.50047
Published online: 18 March 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Pediatric medicine

Women's health

Statistics, epidemiology and research design

Sexual health

Environment and public health

Social determinants of health

Lack of national abortion data impedes development of sexual and reproductive health care policies and programs for young Australians

Recent data show a steady decrease in adolescent births to a historic low of 10 births per 1000 15–19‐year‐olds.1 Notwithstanding that some adolescent pregnancies are planned or wanted, these data are surely positive, as pregnant adolescents are vulnerable to numerous adversities and delaying pregnancy is healthier for mothers and children.2 However, birth rates reflect access to comprehensive sexuality education, reliable contraception and safe abortion. Specifically, as lower birth rates may reflect higher abortion rates, a complete national picture is required. More broadly, pregnancy and its outcomes reflect various inequities that continue to affect adolescents and their offspring across their lives. Greater understanding of adolescent pregnancy outcomes, including abortion, would help shape a suite of interventions for vulnerable adolescents, including interventions that facilitate access to quality schooling and alleviate poverty.

1 Royal Women's Hospital, Melbourne, VIC
2 University of Melbourne, Melbourne, VIC
3 Murdoch Children's Research Institute, Melbourne, VIC

Correspondence: jennifer.marino@unimelb.edu.au

Acknowledgements:

Jennifer Marino is supported by National Health and Medical Research Council Centre of Research Excellence in Adolescent Health grant 1134894 and project grant 1161145. We thank Dr Deborah Bateson (Family Planning Victoria), Ms Sarah Gafforini and Dr Philip Goldstone (Marie Stopes Australia), Dr Cedric Manen (Family Planning Tasmania) and Prof Rachel Skinner (University of Sydney and Children's Hospital Westmead) for enlightening conversations about this topic and comments on the manuscript.

Competing interests:

No relevant disclosures.

1. Australian Bureau of Statistics. 3301.0 – Births, Australia, 2017. Canberra: ABS, 2018. http://www.abs.gov.au/ausstats/abs@.nsf/mf/3301.0 (viewed Feb 2019).
2. Marino JL, Lewis LN, Bateson D, et al. Teenage mothers. Aust Fam Phys 2016; 45: 712–717.
3. Sedgh G, Finer LB, Bankole A, et al. Adolescent pregnancy, birth, and abortion rates across countries: levels and recent trends. J Adolescent Health 2015; 56: 223–230.
4. Singh S, Remez L, Sedgh G, et al. Abortion worldwide 2017: uneven progress and unequal access. New York: Guttmacher Institute, 2018. https://www.guttmacher.org/sites/default/files/report_pdf/abortion-worldwide-2017.pdf (viewed Sept 2018).
5. Centers for Disease Control and Prevention. CDCs abortion surveillance system FAQs. Atlanta, GA: CDC, 2017. https://www.cdc.gov/reproductivehealth/data_stats/abortion.htm (viewed Sept 2018).
6. Sanci LA, Sawyer SM, Kang MS, et al. Confidential health care for adolescents: reconciling clinical evidence with family values. Med J Aust 2005; 183: 410–414. https://www.mja.com.au/journal/2005/183/8/confidential-health-care-adolescents-reconciling-clinical-evidence-family-values
7. Pregnancy Outcome Unit. Pregnancy outcome in South Australia 2016. Adelaide: SA Health, Government of South Australia, 2018. https://www.sahealth.sa.gov.au/wps/wcm/connect/4ccbba85-14c6-4b39-a19e-4e8cd54e9ea1/Pregnancy+Outcome+in+South+Australia+2016.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-4ccbba85-14c6-4b39-a19e-4e8cd54e9ea1-mxUFP3N (viewed Feb 2019).
8. Hutchinson M, Ballestas T. Induced abortions in Western Australia 2013‐2015: fifth report of the Western Australian Abortion Notification System. Perth: Department of Health, Western Australia, 2018. https://ww2.health.wa.gov.au/~/media/Files/Corporate/general%20documents/Data%20collection/PDF/Induced-Abortion-Report-2013-15.pdf (viewed Sept 2018).
9. Part K, Moreau C, Donati S, et al. Teenage pregnancies in the European Union in the context of legislation and youth sexual and reproductive health services. Acta Obstet Gynecol Scand 2013; 92: 1395–1406.
10. Wellings K, Palmer MJ, Geary RS, et al. Changes in conceptions in women younger than 18 years and the circumstances of young mothers in England in 2000‐12: an observational study. Lancet 2016; 388: 586–595.
11. Hadley A, Ingham R, Chandra‐Mouli V. Implementing the United Kingdom's ten‐year teenage pregnancy strategy for England (1999‐2010): how was this done and what did it achieve? Reprod Health 2016; 13: 139.

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Research

The burden of pancreatic cancer in Australia attributable to smoking

Maria E Arriaga, Claire M Vajdic, Robert J MacInnis, Karen Canfell, Dianna J Magliano, Jonathan E Shaw, Julie E Byles, Graham G Giles, Anne W Taylor, Tiffany K Gill, Vasant Hirani, Robert G Cumming, R Paul Mitchell, Emily Banks, Julie Marker, Barbara‐Ann Adelstein and Maarit A Laaksonen

Med J Aust 2019; 210 (5): . || doi: 10.5694/mja2.12108
Published online: 11 March 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Digestive system diseases

Environment and public health

Neoplasms

Nutritional and metabolic diseases

Statistics, epidemiology and research design

Abstract

Objective: To estimate the burden of pancreatic cancer in Australia attributable to modifiable exposures, particularly smoking.

Design: Prospective pooled cohort study.

Setting, participants: Seven prospective Australian study cohorts (total sample size, 365 084 adults); participant data linked to national registries to identify cases of pancreatic cancer and deaths.

Main outcome measures: Associations between exposures and incidence of pancreatic cancer, estimated in a proportional hazards model, adjusted for age, sex, study, and other exposures; future burden of pancreatic cancer avoidable by changes in exposure estimated as population attributable fractions (PAFs) for whole population and for specific population subgroups with a method accounting for competing risk of death.

Results: There were 604 incident cases of pancreatic cancer during the first 10 years of follow‐up. Current and recent smoking explained 21.7% (95% CI, 13.8–28.9%) and current smoking alone explained 15.3% (95% CI, 8.6–22.6%) of future pancreatic cancer burden. This proportion of the burden would be avoidable over 25 years were current smokers to quit and there were no new smokers. The burden attributable to current smoking is greater for men (23.9%; 95% CI, 13.3–33.3%) than for women (7.2%; 95% CI, –0.4% to 14.2%; P = 0.007) and for those under 65 (19.0%; 95% CI, 8.1–28.6%) than for older people (6.6%; 95% CI, 1.9–11.1%; P = 0.030). There were no independent relationships between body mass index or alcohol consumption and pancreatic cancer.

Conclusions: Strategies that reduce the uptake of smoking and encourage current smokers to quit could substantially reduce the future incidence of pancreatic cancer in Australia, particularly among men.

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1 Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW
2 Cancer Council Victoria, Melbourne, VIC
3 Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC
4 Cancer Council NSW, Sydney, NSW
5 University of Sydney, Sydney, NSW
6 Prince of Wales Clinical School, University of New South Wales, Sydney, NSW
7 Baker Heart and Diabetes Institute, Melbourne, VIC
8 Research Centre for Gender, Health and Ageing, University of Newcastle, Newcastle, NSW
9 Adelaide Medical School, University of Adelaide, Adelaide, SA
10 Charles Perkins Centre, University of Sydney, Sydney, NSW
11 ANZAC Research Institute, University of Sydney and Concord Hospital, Sydney, NSW
12 Centre for Vision Research, Westmead Institute for Medical Research, University of Sydney, Sydney, NSW
13 Australian National University, Canberra, ACT
14 Cancer Voices South Australia, Adelaide, SA

Correspondence: m.laaksonen@unsw.edu.au

Acknowledgements:

We thank the investigators and participants of the participating cohort studies and surveys for providing the data for the cohort consortium. Our investigation was supported by the National Health and Medical Research Council (NHMRC; 1060991). The NHMRC also supported Maarit Laaksonen (I1053642), Karen Canfell (1082989), Emily Banks (1136128), Jonathan Shaw (1079438) and Dianna Magliano (1118161). Maarit Laaksonen was also supported by the Cancer Institute NSW (13/ECF/1‐07). Maria Arriaga was supported by an Australian Postgraduate Award and a Translational Cancer Research Network PhD Scholarship Top‐up Award.Details of funding and data sources for the 45 and Up Study (www.saxinstitute.org.au/our-work/45-up-study/for-partners) and the Australian Longitudinal Study on Women's Health (www.alswh.org) are available on the study websites. Cohort recruitment for the Melbourne Collaborative Cohort Study was funded by Cancer Council Victoria and the Victorian Health Promotion Foundation (VicHealth); the study was supported by NHMRC grants 209057 and 396414 and by Cancer Council Victoria (infrastructure support). The CHAMP study is funded by the NHMRC (301916) and the Ageing and Alzheimer's Institute, Sydney. We acknowledge the assistance of the Data Linkage Unit at the Australian Institute of Health and Welfare for undertaking the data linkage to the Australian Cancer Database and the National Death Index.

Competing interests:

No relevant disclosures.

1. Australian Institute of Health and Welfare. Cancer in Australia 2017 (Cancer Series No. 101; Cat. No. CAN 100). Canberra: AIHW, 2017.
2. International Agency for Research on Cancer. A review of human carcinogens. Volume 100E: Personal habits and indoor combustions (IARC Monographs on the Evaluation of Carcinogenic Risks to Humans). Lyon: IARC, 2012. http://monographs.iarc.fr/ENG/Monographs/vol100E/mono100E.pdf (viewed May 2018).
3. Lauby‐Secretan B, Scoccianti C, Loomis D, et al. Body fatness and cancer: viewpoint of the IARC Working Group. N Engl J Med 2016; 375: 794–798.
4. World Cancer Research Fund; American Institute for Cancer Research. Diet, nutrition, physical activity and pancreatic cancer. 2012; revised 2018. https://wcrf.org/sites/default/files/Pancreatic-cancer-report.pdf (viewed May 2018).
5. Arriaga ME, Vajdic CM, Canfell K, et al. The burden of cancer attributable to modifiable risk factors: the Australian cancer–PAF cohort consortium. BMJ Open 2017; 7: e016178.
6. Australian Bureau of Statistics. 4324.0.55.001. Microdata: National Health Survey, 2014–15. May 2016. http://www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/4324.0.55.001Main%20Features12014-15?opendocument&tabname=Summary&prodno=4324.0.55.001&issue=2014-15&num=&view= (viewed Nov 2018).
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16. Bosetti C, Lucenteforte E, Silverman DT, et al. Cigarette smoking and pancreatic cancer: an analysis from the International Pancreatic Cancer Case‐Control Consortium (Panc4). Ann Oncol 2012; 23: 1880–1888.
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19. Michaud DS, Vrieling A, Jiao L, et al. Alcohol intake and pancreatic cancer: a pooled analysis from the pancreatic cancer cohort consortium (PanScan). Cancer Causes Control 2010; 21: 1213–1225.
20. Naudin S, Li K, Jaouen T, et al. Lifetime and baseline alcohol intakes and risk of pancreatic cancer in the European Prospective Investigation into Cancer and Nutrition study. Int J Cancer 2018; 143: 801–812.
21. Duell EJ. Epidemiology and potential mechanisms of tobacco smoking and heavy alcohol consumption in pancreatic cancer. Mol Carcinog 2012; 51: 40–52.
22. Genkinger JM, Spiegelman D, Anderson KE, et al. A pooled analysis of 14 cohort studies of anthropometric factors and pancreatic cancer risk. Int J Cancer 2011; 129: 1708–1717.
23. Kendall BJ, Wilson LF, Olsen CM, et al. Cancers in Australia in 2010 attributable to overweight and obesity. Aust N Z J Public Health 2015; 39: 452–457.
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Research

Identifying the cultural heritage of patients during clinical handover and in hospital medical records

David JR Morgan, Tania Harris, Ron Gidgup and Martin Whitely

Med J Aust 2019; 210 (5): . || doi: 10.5694/mja2.12107
Published online: 11 March 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Environment and public health

General medicine

Global health

Health services administration

Indigenous health

Social determinants of health

Abstract

Objective: To examine the frequency of and rationale for hospital doctors mentioning a patient's cultural heritage (ethnicity, national heritage, religion) during medical handovers and in medical records.

Design: Four‐phase observational study, including the covert observation of clinical handovers in an acute care unit (ACU) and analysis of electronic medical records (EMRs) of ACU patients after their discharge to ward‐based care.

Setting, participants: 1018 patients and the doctors who cared for them at a tertiary hospital in Western Australia, May 2016 – February 2018.

Main outcome measure: References to patients’ cultural heritage by ACU doctors during clinical handover (written or verbal) and by ward‐based doctors in hospital EMRs (written only), by geographic ethnic–national group.

Results: In 2727 ACU clinical handovers of 1018 patients, 142 cultural heritage identifications were made (ethnicity, 84; nationality, 41; religion, 17); the rate was highest for Aboriginal patients (370 [95% CI, 293–460] identifications per 1000 handovers). 14 505 EMR pages were reviewed; 380 cultural heritage identifications (ethnicity, 257; nationality, 119; religion, 4) were recorded. A rationale for identification was documented for 25 of 142 patients (18%) whose ethnic–national background was mentioned during handover or in their EMR. Multivariate analysis (adjusted for demographic, socio‐economic and medical factors) indicated that being an Aboriginal Australian was the most significant factor for identifying ethnic–national background (handovers: adjusted odds ratio [aOR], 21.7; 95% CI, 7.94–59.4; hospital EMRs: aOR, 13.6; 95% CI, 5.03–36.5). 44 of 75 respondents to a post‐study survey (59%) were aware that Aboriginal heritage was mentioned more frequently than other cultural backgrounds.

Conclusions: Explicitly mentioning the cultural heritage of patients is inconsistent and seldom explained. After adjusting for other factors, Aboriginal patients were significantly more likely to be identified than patients with other backgrounds.

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1 South Metroplitan Health Service, Perth, WA
2 Health Consumers’ Council (WA), Perth, WA
3 John Curtin Institute of Public Policy, Curtin University, Perth, WA

Correspondence: david.morgan@health.wa.gov.au

Acknowledgements:

We thank Jenny Thompson for assisting with the collection of the APACHE III data.

Competing interests:

No relevant disclosures.

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Narrative review

Current management of glaucoma

Jed Lusthaus and Ivan Goldberg

Med J Aust 2019; 210 (4): . || doi: 10.5694/mja2.50020
Published online: 4 March 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Eye diseases

Surgical procedures, operative

Summary

Glaucoma is an irreversible progressive optic neuropathy, for which the major proven treatment is to lower the intraocular pressure (IOP).
Five groups of IOP‐lowering eye drops have varying mechanisms of action. Some drops, such as β‐blockers and α‐2 agonists, have potentially serious systemic side effects. Acetazolamide is the only available oral agent; it is effective at lowering IOP, but significant side effects relegate its use usually to refractory glaucoma.
Two new eye drops, netarsudil and latanoprostene bunod, have recently been approved by the United States Food and Drug Administration. Both have novel IOP‐lowering mechanisms and target the conventional aqueous outflow system.
Selective laser trabeculoplasty is a gentle treatment that enhances conventional aqueous outflow. It may be used as an initial treatment, as a substitute for eye drops, or to delay glaucoma drainage surgery.
Recent advancements in glaucoma surgery have seen an influx of minimally invasive glaucoma surgery devices, which are being used more frequently and earlier on in the treatment paradigm. As limited long term data are available, trabeculectomy remains the gold standard IOP‐lowering procedure. Improvements in drug delivery are on the horizon. Drug‐eluting devices and implants are able to deliver the drug closer to the receptors for an extended period of time. This will improve treatment adherence and efficacy, which are major limitations with current medical therapy.

1 University of Sydney, Sydney, NSW
2 Sydney Hospital and Sydney Eye Hospital, Sydney, NSW

Correspondence: eyeGoldberg@gmail.com

Competing interests:

No relevant disclosures.

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