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    Botulinum toxin for spasticity: a case for change to the Pharmaceutical Benefits Scheme

    Anupam Datta Gupta and David H Wilson
    Med J Aust 2018; 208 (9): . || doi: 10.5694/mja17.00841
    Published online: 29 January 2018

    Current permissible use of botulinum toxin in Australia does not match newer understandings of human impairment and functioning

    The bacterium Clostridium botulinum was first identified in 1895 and, in the 1950s, was first injected into a hyperactive muscle, causing flaccid paralysis by blocking the release of the neurotransmitter acetylcholine from motor nerve endings. However, the therapeutic use of botulinum toxin only became common after 1989, when it was approved for use for strabismus, and then in 2001, when it was synthesised and approved for use as a cosmetic treatment in Canada. In 2017, the idea of paralysing the muscles of the brow and face with a powerful neurotoxin for cosmetic reasons is now widely accepted, or at least conceptually understood, because of frequent reference to the popular procedure in the media.


    • Queen Elizabeth Hospital, Adelaide, SA


    Correspondence: adattagupta86@gmail.com
    Acknowledgements: 

    We thank Barbara Brougham for editing earlier versions of this article.

    Competing interests:

    No relevant disclosures.

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      Salt consumption by Australian adults: a systematic review and meta-analysis

      Mary-Anne Land, Bruce C Neal, Claire Johnson, Caryl A Nowson, Claire Margerison and Kristina S Petersen
      Med J Aust 2018; 208 (2): . || doi: 10.5694/mja17.00394
      Published online: 29 January 2018

      Abstract

      Objective: Salt reduction is a public health priority because it is a leading contributor to the global burden of disease. As in Australia there is uncertainty about the current level of salt intake, we sought to estimate current levels.

      Study design: Random effects meta-analysis of data from 31 published studies and one unpublished dataset that reported salt or sodium consumption by Australian adults on the basis of 24-hour urine collections or dietary questionnaires.

      Data sources: MEDLINE (via Ovid) and EMBASE (to August 2016).

      Data synthesis: Thirty-one published studies and one unpublished dataset (1989–2015; 16 836 individuals) were identified. The mean weighted salt consumption estimated from 24-hour urine collections was 8.70 g/day (95% CI, 8.39–9.02 g/day); after adjusting for non-urinary salt excretion, the best estimate of salt intake in Australia is 9.6 g/day. The mean weighted intake was 10.1 g/day (95% CI, 9.68–10.5 g/day) for men and 7.34 g/day (95% CI, 6.98–7.70 g/day) for women. Mean weighted consumption was 6.49 g/day (95% CI, 5.94–7.03 g/day) when measured with diet diaries, 6.76 g/day (95% CI, 5.48–8.05 g/day) when assessed with food frequency questionnaires, and 6.73 g/day (95% CI, 6.34–7.11) when assessed by dietary recall. Salt intake had not decreased between 1989 and 2015 (R2 = –0.02; P = 0.36).

      Conclusion: Salt intake in Australian adults exceeds the WHO-recommended maximum of 5 g/day and does not appear to be declining. Measuring salt intake with methods based on self-reporting can substantially underestimate consumption. The data highlight the need for ongoing action to reduce salt consumption in Australia and robust monitoring of population salt intake.


      • 1 The George Institute for Global Health, Sydney, NSW
      • 2 Institute for Physical Activity and Nutrition, Deakin University, Geelong, VIC


      Acknowledgements: 

      Bruce Neal is supported by a National Health and Medical Research Council (NHMRC) Principal Research Fellowship. He holds an NHMRC Centre for Research Excellence grant (APP1117300) and an NHMRC program grant (APP1052555).

      Competing interests:

      No relevant disclosures.

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        A self-management support program for older Australians with multiple chronic conditions: a randomised controlled trial

        Richard L Reed, Leigh Roeger, Sara Howard, Jodie M Oliver-Baxter, Malcolm W Battersby, Malcolm Bond and Richard H Osborne
        Med J Aust 2018; 208 (2): . || doi: 10.5694/mja17.00127
        Published online: 22 January 2018

        Abstract

        Objective: To determine whether a clinician-led chronic disease self-management support (CDSMS) program improves the overall self-rated health level of older Australians with multiple chronic health conditions.

        Design: Randomised controlled trial: participants were allocated to a clinician-led CDSMS group (including client-centred goal setting and the development of individualised care plans) or to a control group in which they received positive attention only.

        Setting and participants: Patients aged 60 years or more with at least two chronic conditions, recruited between September 2009 and June 2010 from five general practices in Adelaide.

        Main outcome measures: The primary outcome was self-rated health. Secondary outcome measures related to health status (fatigue, pain, health distress, energy, depression, illness intrusiveness), health behaviour (exercise, medication adherence), and health service utilisation.

        Results: 254 participants were randomised to the CDSMS and control groups, of whom 231 (117 control and 114 CDSMS participants) completed the 6-month programs and provided complete outcomes data (91%). An intention-to-treat analysis found that CDSMS participants were more likely than control participants to report improved self-rated health at 6 months (odds ratio, 2.50; 95% confidence interval, 1.13–5.50; P = 0.023). Between-group differences for secondary outcomes were not statistically significant.

        Conclusion: CDSMS may benefit some older people with multiple chronic conditions to a greater extent than positive attention and health education.

        Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12609000726257.

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        • 1 Flinders University, Adelaide, SA
        • 2 Flinders Human Behaviour and Health Services Unit, Flinders University, Adelaide, SA
        • 3 Health System Improvement Unit, Centre for Population Health Research, Deakin University, Geelong, VIC


        Acknowledgements: 

        This investigation was supported by a grant to Flinders University from the Australian Department of Health and Ageing (DoHA) under the Sharing Health Care Initiative – Innovations in Chronic Disease Self-Management Research Grants program. The DoHA had no role in the study design, collection, analysis, and interpretation of data, writing of the article, or the decision to submit it for publication. We thank the patients and general practitioners from Chandlers Hill, Flagstaff Hill and Colonel Light Gardens, and Chris Moschou for their support. We also thank members of the research team for their contributions: the Flinders Program adviser (Vee Pols), Flinders Program clinicians (Angela Eastwood, Katrina Reschke, Melissa Day, Pauline Kelly), attention control group health professionals (Lauren Bullivant, Marie Iannos), our research nurse (Bridgit McAteer-Carr), and the qualitative researchers (Chris Barton, Linda Isherwood, Stacey Masters). Richard Osborne was supported in part by a National Health and Medical Research Council Population Health Research Fellowship (Career Development Award).

        Competing interests:

        Malcom Battersby is the developer of the Flinders Program. He has no financial interest in the Flinders Program, but Flinders University has received funding from government, commercial and charitable sponsors for the research, development and dissemination of the Flinders Program.

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          Position statement: a clinical approach to the management of adult non-neurogenic overactive bladder

          Eric Chung, Dominic Lee, Johan Gani, Michael Gillman, Christopher Maher, Janelle Brennan, Lydia Johns Putra, Laura Ahmad and Lewis LW Chan
          Med J Aust 2018; 208 (1): . || doi: 10.5694/mja16.01097
          Published online: 15 January 2018

          Summary

          Introduction: Overactive bladder (OAB) is a highly prevalent medical condition that has an adverse impact on various health-related quality-of-life domains, including a significant psychosocial and financial burden. This position statement, formulated by members of the Urological Society of Australia and New Zealand and the UroGynaecological Society of Australasia, summarises the current recommendations for clinical diagnosis and treatment strategies in patients with non-neurogenic OAB, and guides clinicians in the decision-making process for managing the condition using evidence-based medicine.

          Main recommendations:

          • Diagnosis and initial management should be based on thorough clinical history, examination and basic investigations to exclude underlying treatable causes such as urinary tract infection and urological malignancy.
          • Initial treatment strategies for OAB involve conservative management with behavioural modification and bladder retraining.
          • Second-line management involves medical therapy using anticholinergic or β3 agonist drugs provided there is adequate assessment of bladder emptying.
          • If medical therapy is unsuccessful, further investigations with urodynamic studies and cystourethroscopy are recommended to guide further treatment.
          • Intravesical botulinum toxin and sacral neuromodulation should be considered in medical refractory OAB.

          Changes in management as a result of this statement:

          • OAB is a constellation of urinary symptoms and is a chronic condition with a low likelihood of cure; managing patient expectations is essential because OAB is challenging to treat.
          • At present, the exact pathogenesis of OAB remains unclear and it is likely that there are multiple factors involved in this disease complex.
          • Current medical treatment remains far from ideal, although minimally invasive surgery can be effective.
          • Further research into the pathophysiology of this common condition will hopefully guide future developments in disease management.

          • 1 Princess Alexandra Hospital, Brisbane, QLD
          • 2 St George Hospital, Sydney, NSW
          • 3 Austin and Repatriation Hospital, Melbourne, VIC
          • 4 Pelvic Medicine Centre, St Andrews War Memorial Hospital, Brisbane, QLD
          • 5 Royal Brisbane and Women's Hospital, Brisbane, QLD
          • 6 Bendigo Health, Bendigo, VIC
          • 7 Ballarat Urology, Ballarat, VIC
          • 8 Ballarat Health Services, Ballarat, VIC
          • 9 Aged Health Network, NSW Agency for Clinical Innovation, Sydney, NSW
          • 10 Concord Repatriation General Hospital, Sydney, NSW


          Correspondence: ericchg@hotmail.com
          Competing interests:

          No relevant disclosures.

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            Cognitive impairment during pregnancy: a meta-analysis

            Sasha J Davies, Jarrad AG Lum, Helen Skouteris, Linda K Byrne and Melissa J Hayden
            Med J Aust 2018; 208 (1): . || doi: 10.5694/mja17.00131
            Published online: 15 January 2018

            Abstract

            Objectives: Many women report declines in cognitive function during pregnancy, but attempts to empirically evaluate such changes have yielded inconsistent results. We aimed to determine whether pregnancy is associated with objective declines in cognitive functioning, and to assess the progression of any declines during pregnancy.

            Study design: We undertook a meta-analysis, applying a random effects model, of 20 studies that have reported quantitative relationships between pregnancy and changes in cognition.

            Data sources: Full text articles indexed by Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete, MEDLINE Complete, and PsychINFO.

            Data synthesis: The 20 studies assessed included 709 pregnant women and 521 non-pregnant women. Overall cognitive functioning was poorer in pregnant women than in non-pregnant women (standardised mean difference [SMD], 0.52 [95% CI, 0.07–0.97]; P = 0.025). Analysis of cross-sectional studies found that general cognitive functioning (SMD, 1.28 [95% CI 0.26–2.30]; P = 0.014), memory (SMD, 1.47 [95% CI, 0.27–2.68]; P = 0.017), and executive functioning (SMD, 0.46 [95% CI, 0.03–0.89]; P = 0.036) were significantly reduced during the third trimester of pregnancy (compared with control women), but not during the first two trimesters. Longitudinal studies found declines between the first and second trimesters in general cognitive functioning (SMD, 0.29 [95% CI, 0.08–0.50]; P = 0.006) and memory (SMD, 0.33 [95% CI, 0.12–0.54]; P = 0.002), but not between the second and third trimesters.

            Conclusions: General cognitive functioning, memory, and executive functioning were significantly poorer in pregnant than in control women, particularly during the third trimester. The differences primarily develop during the first trimester, and are consistent with recent findings of long term reductions in brain grey matter volume during pregnancy. The impact of these effects on the quality of life and everyday functioning of pregnant women requires further investigation.


            • Deakin University, Melbourne, VIC


            Correspondence: m.hayden@deakin.edu.au
            Competing interests:

            No relevant disclosures.

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              Diagnosing COPD and supporting smoking cessation in general practice: evidence–practice gaps

              Jenifer Liang, Michael J Abramson, Nicholas A Zwar, Grant M Russell, Anne E Holland, Billie Bonevski, Ajay Mahal, Kirsten Phillips, Paula Eustace, Eldho Paul, Sally Wilson and Johnson George
              Med J Aust 2018; 208 (1): . || doi: 10.5694/mja17.00664
              Published online: 15 January 2018

              Abstract

              Objectives: To review the accuracy of diagnoses of chronic obstructive pulmonary disease (COPD) in primary care in Australia, and to describe smokers’ experiences with and preferences for smoking cessation.

              Design, setting and participants: Patients were invited to participate if they were at least 40 years old and had visited participating general practice clinics in Melbourne at least twice during the previous 12 months, reported being current or ex-smokers with a smoking history of at least 10 pack-years, or were being managed for COPD. Interviews based on a structured questionnaire and case finding (FEV1/FEV6 measurement) were followed, when appropriate, by spirometry testing and assessment of health-related quality of life, dyspnoea and symptoms.

              Results: 1050 patients attended baseline interviews (February 2015 – April 2017) at 41 practices. Of 245 participants managed for COPD, 130 (53.1%) met the spirometry-based definition (post-bronchodilator FEV1/FVC < 0.7) or had a clinical correlation; in 37% of cases COPD was not confirmed, and no definitive result was obtained for 9.8% of patients. Case finding and subsequent spirometry testing identified 142 new COPD cases (17.6% of participants without prior diagnosis; 95% CI, 15.1–20.5%). 690 participants (65.7%) were current smokers, of whom 360 had attempted quitting during the previous 12 months; 286 (81.0% of those attempting to quit) reported difficulties during previous quit attempts. Nicotine replacement therapy (205, 57.4%) and varenicline (110, 30.8%) were the most frequently employed pharmacological treatments; side effects were common. Hypnotherapy was the most popular non-pharmacological option (62 smokers, 17%); e-cigarettes were tried by 38 (11%). 187 current smokers (27.6%) would consider using e-cigarettes in future attempts to quit.

              Conclusions: COPD was both misdiagnosed and missed. Case finding and effective use of spirometry testing could improve diagnosis. Side effects of smoking cessation medications and difficulties during attempts to quit smoking are common. Health professionals should emphasise evidence-based treatments, and closely monitor quitting difficulties and side effects of cessation aids.

              Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12614001155684.

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              • 1 Centre for Medicine Use and Safety, Monash University, Melbourne, VIC
              • 2 Monash University, Melbourne, VIC
              • 3 University of New South Wales, Sydney, NSW
              • 4 University of Wollongong, Wollongong, NSW
              • 5 Southern Academic Primary Care Research Unit, Monash University, Melbourne, VIC
              • 6 La Trobe University, Melbourne, VIC
              • 7 Alfred Health, Melbourne, VIC
              • 8 Institute for Breathing and Sleep, Austin Hospital, Melbourne, VIC
              • 9 University of Newcastle, Newcastle, VIC
              • 10 The Nossal Institute for Global Health, University of Melbourne, Melbourne, VIC
              • 11 Lung Foundation Australia, Brisbane, QLD
              • 12 Eastern Melbourne PHN, Melbourne, VIC
              • 13 Alfred Hospital, Melbourne, VIC


              Correspondence: Johnson.George@monash.edu
              Acknowledgements: 

              This trial is funded by the National Health and Medical Research Council (NHMRC) through the NHMRC Partnerships for Better Health – Partnership Projects initiative (APP1076255). Cash and in-kind contributions were received from our partner organisations, Lung Foundation Australia (LFA), Boehringer Ingelheim, and Eastern Melbourne PHN (EMPHN). The LFA and EMPHN were involved in project design and conduct, and contributed to data analysis and writing of manuscripts. Boehringer Ingelheim was involved in project discussions, planning and progress review, but had no involvement in the design of the intervention program, and did not contribute to decisions about data analysis and the dissemination of findings. Billie Bonevski is supported by an NHMRC Career Development Fellowship (GNT1063206) and a Faculty of Health and Medicine, University of Newcastle, Gladys M. Brawn Career Development Fellowship. Jenifer Liang receives the Cyril Tonkin Scholarship 2014, administered by the Victorian College of Pharmacy Foundation Board, Monash University. We thank Denise van den Bosch (project manager), and all research assistants, clinics and participants.

              Competing interests:

              Johnson George, Billie Bonevski and Michael J Abramson have held an investigator-initiated grant from Pfizer for unrelated research. Michael J Abramson has received assistance for conference attendance from Sanofi. Johnson George and Nicholas A Zwar are members of the Lung Foundation Australia COPD Guidelines Committee; Michael J Abramson was Chair of the committee (2004–14). Anne E Holland is a member of the Lung Foundation Australia COPD-XConcise Guide for Primary Care Advisory Committee. Kirsten Phillips is general manager of the COPD National Program, Lung Foundation Australia.

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                Comorbidities in Australian women with hormone-dependent breast cancer: a population-based analysis

                Huah Shin Ng, Bogda Koczwara, David M Roder, Theo Niyonsenga and Agnes I Vitry
                Med J Aust 2018; 208 (1): . || doi: 10.5694/mja17.00006
                Published online: 15 January 2018

                Abstract

                Objective: To compare how frequently selected chronic diseases developed in women with breast cancer receiving endocrine therapy, and in women without cancer.

                Design, setting and participants: Retrospective, rolling cohort study, analysing a random 10% sample of Pharmaceutical Benefits Scheme (PBS) data for the period 1 January 2003 – 31 December 2014. Women with breast cancer who first commenced endocrine therapy between January 2004 and December 2011 were identified, and age- and sex-matched (1:10) by comorbidity with control groups of women who did not have a dispensing record for antineoplastic agents during the study period or the comorbidity of interest at baseline.

                Main outcome measures: Development of any of eight pre-selected comorbidities, identified in PBS claims data with the RxRisk-V model.

                Results: Women with hormone-dependent breast cancer were significantly more likely than women in the control group to develop depression (overall hazard ratio [HR], 1.36; 95% CI, 1.26–1.46), pain or pain–inflammation (HR, 1.30; 95% CI, 1.23–1.38), osteoporosis (overall HR, 1.27; 95% CI, 1.17–1.39), diabetes (HR, 1.24; 95% CI, 1.10–1.41), cardiovascular disorders (overall HR, 1.22; 95% CI, 1.13–1.32), and gastric acid disorders (HR, 1.20; 95% CI, 1.13–1.28). The hazard ratios for developing cardiovascular disorders, depression and osteoporosis were highest during the first year of endocrine therapy. The risk of hyperlipidaemia was lower among women with breast cancer than in the control group (HR, 0.88; 95% CI, 0.81–0.96). There was no significant difference between the two groups in the risk of reactive airway diseases (HR, 1.05; 95% CI, 0.98–1.13).

                Conclusion: Comorbid conditions are more likely to develop in women who have been diagnosed with hormone-dependent breast cancer than in women without cancer. Our results further support the need to develop appropriate models of care to manage the multiple chronic disorders of breast cancer survivors.

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                • 1 University of South Australia, Adelaide, SA
                • 2 Flinders Medical Centre, Adelaide, SA
                • 3 Flinders Centre for Innovation in Cancer, Flinders University, Adelaide, SA
                • 4 Centre for Population Health Research, University of South Australia, Adelaide, SA
                • 5 Health Research Institute/CeRAPH, University of Canberra, Canberra, ACT


                Acknowledgements: 

                Huah Shin Ng is supported by an Australian Government Research Training Program Scholarship.

                Competing interests:

                No relevant disclosures.

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                  The impact of non-vitamin K antagonist oral anticoagulants (NOACs) on anticoagulation therapy in rural Australia

                  Jamie W Bellinge, Jarrad J Paul, Liam S Walsh, Lokesh Garg, Gerald F Watts and Carl Schultz
                  Med J Aust 2018; 208 (1): . || doi: 10.5694/mja17.00132
                  Published online: 15 January 2018

                  Abstract

                  Objective: To determine the use of different anticoagulation therapies in rural Western Australia; to establish whether remoteness from health care services affects the choice of anticoagulation therapy; to gather preliminary data on anticoagulation therapy safety and efficacy.

                  Design: Retrospective cohort study of patients hospitalised with a principal diagnosis of atrial fibrillation/flutter (AF) or venous thromboembolism (VTE) during 2014–2015.

                  Setting: Four hospitals serving two-thirds of the rural population of Western Australia.

                  Participants: 609 patients with an indication for anticoagulation therapy recorded in their hospital discharge summary for index admission.

                  Main outcome measures: Prescribing rates of anticoagulation therapies by indication for anticoagulation and distance of patient residence from their hospital. The primary safety outcome was re-hospitalisation with a major or clinically relevant non-major bleeding event; the primary lack-of-efficacy outcome was re-hospitalisation for a thromboembolic event.

                  Results: The overall rates of prescription of NOACs and warfarin were similar (34% v 33%). A NOAC was prescribed more often than warfarin for patients with AF (56.0% v 42.2% of those who received an anticoagulant; P < 0.001), but less often for patients with VTE (29% v 48%; P < 0.001). Warfarin was prescribed for 38% of patients who lived locally, a NOAC for 31% (P = 0.013); for non-local patients, the respective proportions were 29% and 36% (P = 0.08). 69% of patients with AF and a CHA2DS2–VASc score ≥ 1 were prescribed anticoagulation therapy. Patients treated with NOACs had fewer bleeding events than patients treated with warfarin (nine events [4%] v 20 events [10%]; P = 0.027).

                  Conclusions: In rural WA, about one-third of patients with an indication for anticoagulation therapy receive NOACs, but one-third of patients with AF and at risk of stroke received no anticoagulant therapy, and may benefit from NOAC therapy.

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                  • 1 Royal Perth Hospital, Perth, WA
                  • 2 Bunbury Regional Hospital, Bunbury, WA
                  • 3 South West Health Campus, Bunbury, WA
                  • 4 University of Western Australia, Perth, WA


                  Competing interests:

                  No relevant disclosures.

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                    Investing in men’s health in Australia

                    James A Smith, Mick Adams and Jason Bonson
                    Med J Aust 2018; 208 (1): . || doi: 10.5694/mja17.00173
                    Published online: 15 January 2018

                    Building leadership, governance and evaluation capacity to improve men’s health outcomes

                    Research has consistently shown a sex differential in illness and mortality between men and women.1 It is widely acknowledged that this difference relates to a combination of biological and sociological factors, including the social construction of gender.1,2 Empirical evidence shows that life expectancy among men in Australia has raised slightly over the past decade.1 However, the report by the Australian Institute of Health and Welfare The health of Australia’s males1 indicates that some men make healthy lifestyle choices and have positive health outcomes. About two-thirds of men participate in sports or physical activities, nearly 40% discuss health lifestyle concerns with a health professional, 20% rate their health as excellent, and survival rates for prostate cancer and testicular cancer in Australia are improving.1 Yet, popular wisdom would have us believe that men are stoic and do not seek help or use health services.2 There are clear indications that the tides are changing.


                    • 1 Charles Darwin University, Darwin, NT
                    • 2 Australian Indigenous HealthInfoNet, Edith Cowan University, Perth, WA
                    • 3 Men's Health Strategy Unit, Department of Health, Darwin, NT


                    Correspondence: james.smith3@cdu.edu.au
                    Acknowledgements: 

                    We thank the NT Government Department of Local Government and Community Services (now Department of Housing and Community Development) for the provision of a Men’s Leadership Grant to undertake the NT Indigenous Male Research Strategy Think Tank.

                    Competing interests:

                    No relevant disclosures.

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                      Towards a theoretically informed policy against a rakghoul plague outbreak

                      Dimitrios-Georgios Kontopoulos, Theano Kontopoulou, Hsi-Cheng Ho and Bernardo García-Carreras
                      Med J Aust 2017; 207 (11): . || doi: 10.5694/mja17.00792
                      Published online: 11 December 2017

                      Summary

                      A long time ago in a galaxy far, far away, the Sith Lord Karness Muur engineered the rakghoul plague, a disease that transformed infected humans into near-mindless predatory rakghouls. At its peak, the disease infected millions of individuals, giving rise to armies of rakghouls on a number of planets. Whether rakghoul populations have persisted until this day is not known, making a rakghoul invasion on Earth not completely improbable. Further, a strategy for defence against an outbreak of the disease on Earth has not yet been proposed. To fill this glaring gap, we developed the first mathematical model of the population dynamics of humans and rakghouls during a rakghoul plague outbreak. Using New South Wales as a model site, we then obtained ensembles of model predictions for the outcome of the rakghoul plague in two different disease control strategy scenarios (population evacuation and military intervention), and in the absence thereof. Finally, based on these predictions, we propose a set of policy guidelines for successfully controlling and eliminating outbreaks of the rakghoul plague in Australian states.

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                      • 1 Imperial College London, Silwood Park Campus, Ascot, Berkshire, United Kingdom
                      • 2 Evangelismos Hospital, Athens, Greece


                      Acknowledgements: 

                      We thank Samraat Pawar for providing comments on an early draft of our article.

                      Competing interests:

                      No relevant disclosures.

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