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Introduction: The clinical practice guidelines on pregnancy care have been developed to provide reliable and standardised guidance for health professionals providing antenatal care in Australia. They were originally released as the Clinical Practice Guidelines: Antenatal Care in two separate editions (modules 1 and 2) in 2012 and 2014. These modules have now been combined and updated to form a single set of consolidated guidelines that were publicly released in February 2018 as the Clinical Practice Guidelines: Pregnancy Care. Eleven topics have been updated and new guidance on substance use in pregnancy has been added.
Main recommendations: The updated guidelines include the following key changes to practice:
Changes in management as a result of the guidelines: The guidelines will enable pregnant women diagnosed with hepatitis C to be identified and thus avoid invasive procedures that increase the risk of mother-to-baby transmission. Women can be treated postpartum, reducing the risk of liver disease and removing the risk of perinatal infection for subsequent pregnancies. Routine testing of all pregnant women for vitamin D status and subsequent vitamin D supplementation is not supported by evidence and should cease as the benefits and harms of vitamin D supplementation remain unclear. The recommendation for health professionals to provide advice to pregnant women about weight, diet and physical activity, and the opportunity to be weighed will help women to make changes leading to better health outcomes for themselves and their babies.
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The review of the guidelines was jointly funded by the Australian Government and the states and territories. The review was project managed by the Australian Government Department of Health. The authors acknowledge the engagement and support of the Australian College of Midwives, the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives, the Royal Australian College of General Practitioners and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. EWG members who have supported the review of the guidelines: Professor Jeremy Oats, University of Melbourne (co-chair); Professor Caroline Homer, University of Technology Sydney and the Australian College of Midwives (co-chair); Associate Professor Philippa Middleton, South Australian Health and Medical Research Institute Adelaide; Dr Martin Byrne, Royal Australian College of General Practitioners; Ann Catchlove, consumer representative; Lisa Clements, migrant and refugee women representative; Dr Anthony Hobbs, Commonwealth Deputy Chief Medical Officer; Tracy Martin, WA Health; Professor Sue McDonald, La Trobe University; Dr Sarah Jane McEwan, Western Australian Country Hedland Service; Professor Michael Permezel, Royal Australian College of Obstetricians and Gynaecologists; Adjunct Professor Debra Thoms, Commonwealth Chief Nursing and Midwifery Officer; Louis Young, Department of Health (Secretariat); Samantha Diplock, Department of Health (Secretariat); Anita Soar, Department of Health (Secretariat); and Jenny Ramson, Ampersand Health Science Writing (technical writer).
No relevant disclosures.
Parental health prior to conception is increasingly recognised as being important for the health of future generations
Pre-conception care is the provision of health recommendations to women of reproductive age with the goal of improving short and long term health outcomes for both the mothers and their children. It includes an assessment of medical conditions, vaccination status, and lifestyle factors.1 While pre-conception care will benefit any woman contemplating pregnancy, it is particularly important for women with medical conditions such as diabetes and obesity. Nevertheless, it is often underutilised.2 In this article, we describe strategies for overcoming challenges to providing pre-conception care and provide guidance for time-poor clinicians.
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No relevant disclosures.
Pervasive bullying, discrimination and sexual harassment are increasingly hard to ignore, yet evidence of effective interventions is lacking
Unprofessional behaviour is sufficiently widespread in the Australian health care system that it could be considered endemic. The 2016 survey of the Victorian Public Sector Commission found that 25% of staff in health agencies experienced bullying,1 and in a 2014 survey of the Australian Nursing and Midwifery Federation, 40% of nurses reported bullying or harassment in the previous 12 months.2 In 2015, the Royal Australasian College of Surgeons surveyed 3516 surgical Fellows, trainees and international medical graduates and found that 49% had been subjected to discrimination, bullying, harassment or sexual harassment.3 The Australasian College for Emergency Medicine released in 2017 its survey results: 34% of respondents had experienced bullying, 21.7% discrimination, 16.1% harassment and 6.2% sexual harassment.4 Thus, unsurprisingly, the 2016 Senate inquiry into the medical complaints process concluded that bullying, discrimination and harassment levels remain disconcertingly high despite the apparent “zero tolerance” approach reported by medical administrators and colleges.5
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The authors are recipients of a National Health and Medical Research Council Partnership Project Grant (1134459) for this work.
Victoria Atkinson and Catherine Jones are employees of St Vincent’s Health Australia.
Helping doctors build resilience may be protective against burnout and suicide in times of personal hardship
Having successive generations of doctors in one family — a “medical pedigree” — was once a source of great pride. As the daughter of a doctor and now a mother, I am surprised to find myself hoping my own children do not follow in my footsteps. This is not because of my own career dissatisfaction. In fact, my work is immensely rewarding, but recently, I have been reflecting on the hardships a medical career entails: the gruelling training pathway, the complex medical culture and the constant battle to achieve a work–life balance. I have now witnessed the devastating personal consequences when the rocky road seems impossible to navigate. Over a matter of months, two female junior doctors committed suicide, and more recently, suicide entered my inner circle with the death of one my close male colleagues. Such stories are not unusual in our profession. I do not claim any expertise in this field, but what seems clear to me is that inherent traits in the individuals who choose a career in medicine, and often create excellent doctors, also set them up for high rates of distress. We have a medical workforce that has gone through rapid evolutionary change, and if we combine these factors with exposure to dysfunctional aspects of our medical culture or personal stressors, we have ingredients for a perfect storm.
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I thank Yael Barnett for assistance in setting up Vinnies Women in Medicine and reviewing a draft of this manuscript.
No relevant disclosures.
We still await well conducted RCTs of CO2 laser therapy for vaginal atrophy; in the meantime, topical oestrogen therapy remains the gold standard
Vaginal laser therapy has entered the global marketplace promising women relief from symptoms of genitourinary syndrome of menopause (GSM), formerly known as vulvovaginal atrophy.
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Introduction: Screening is an effective means for colorectal cancer prevention and early detection. Family history is strongly associated with colorectal cancer risk. We describe the rationale, evidence and recommendations for colorectal cancer screening by family history for people without a genetic syndrome, as reported in the 2017 revised Australian guidelines.
Main recommendations: Based on 10-year risks of colorectal cancer, people at near average risk due to no or weak family history (category 1) are recommended screening by immunochemical faecal occult blood test (iFOBT) every 2 years from age 50 to 74 years. Individuals with moderate risk due to their family history (category 2) are recommended biennial iFOBT from age 40 to 49 years, then colonoscopy every 5 years from age 50 to 74 years. People with a high risk due to their family history (category 3) are recommended biennial iFOBT from age 35 to 44 years, then colonoscopy every 5 years from age 45 to 74 years.
Changes in management as a result of the guidelines: By 2019, the National Bowel Cancer Screening Program will offer all Australians free biennial iFOBT screening from age 50 to 74 years, consistent with the recommendations in these guidelines for category 1. Compared with the 2005 guidelines, there are some minor changes in the family history inclusion criteria for categories 1 and 2; the genetic syndromes have been removed from category 3 and, as a consequence, colonoscopy screening is now every 5 years; and for categories 2 and 3, screening begins with iFOBT for people aged 40 and 35 years, respectively, before transitioning to colonoscopy after 10 years.
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Mark Jenkins has a Research Fellowship from the NHMRC.
Albert Chetcuti and Laura Wuellner are employed by Cancer Council Australia to assist in the preparation of these guidelines — Cancer Council Australia received financial support from both Cancer Council Australia and the Australian Government Department of Health. Mark Jenkins, Jon Emery, Finlay Macrae and James St. John received travel support from Cancer Council Australia to attend meetings for development of the guidelines. Mark Jenkins, Jon Emery, Finlay Macrae and James St. John are members of the Clinical Advisory Group of the National Bowel Cancer Screening Program and received travel support and sitting fees.
Clinicians are no longer gatekeepers to privileged information, but rather interpreters, problem solvers, and advisers
Many readers will be accessing the MJA via the internet: on computers, laptops, phones, or tablets. It is therefore essential that we discuss and understand how the internet and social media are used by patients to find health information, as well as the influence that the medical profession might have on such online information.
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I am an executive member of Friends of Science in Medicine.
Clinical record
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No relevant disclosures.
An Australian alliance of clinical, consumer, research and public organisations is emerging to tackle overdiagnosis
Overdiagnosis is now a health challenge recognised across many nations.1 Debates about its definition continue, but in short, overdiagnosis happens when health systems routinely diagnose people in ways that do not benefit them or that even do more harm than good.2 Overdiagnosis is unwarranted diagnosis, leading to harms from unnecessary labels and treatments and to the waste of health care resources that could be better spent dealing with genuine needs. To manage overdiagnosis and the sustainability of the health system more broadly, reversing the harm of too much medicine is becoming a health care priority, demanding effective responses in policy and practice. In Australia, a new alliance is developing a national plan to deal with this problem.
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All authors were involved in planning the 2017 National Summit on Overdiagnosis.
Summary