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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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Huah Shin Ng is supported by an Australian Government Research Training Program Scholarship.
No relevant disclosures.
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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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.
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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.
No relevant disclosures.
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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We thank Samraat Pawar for providing comments on an early draft of our article.
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Objective: To evaluate the influence of medical specialty on the likelihood of doctors making the Naughty or Nice lists this Christmas.
Design, setting, and participants: A quantitative observational study. Doctors in a medical parent Facebook group were asked about their specialty and their tendency to follow recipes.
Main outcome measures: Self-reported tendency to follow the recipe (always, sometimes, never) as an indicator of rule-breaking behaviour, extrapolated as indicating Naughty (unlikely to follow a recipe) or Nice (always follow recipes) tendencies, and consequently the likelihood of being included in the Nice list this Christmas.
Results: The majority of doctors in only 19% of specialties made the Nice list. When aggregated, 92% of surgical specialties reported that they either never followed recipes or did so only occasionally. Similarly, 80% of physician specialties reported being Naughty. In contrast, 50% each of those in critical care specialties were Naughty or Nice. General practitioners comprised the largest single group of respondents, and only 8% identified as Nice.
Conclusions: An overwhelming majority of medical parents were Naughty. As Santa makes his list and checks it twice, he will find out who is Naughty or Nice, and he may be surprised at the number of doctors who are on the wrong side of the inventory. When Santa Claus comes to town, he should be circumspect when indulging in any baked offerings by the Christmas tree, particularly those offered by surgeons and general practitioners.
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Objectives: To determine the proportion of children visited by the Tooth Fairy, the child-related factors that influence the likelihood of her visit, and the parent-related variables that affect the amount of money the Tooth Fairy leaves.
Design: Cross-sectional questionnaire study.
Setting: Zürich, Switzerland.
Participants: 3617 parents of children (mean age of children, 6.8 years; 51.9% girls) who had lost at least one deciduous tooth received a self-developed questionnaire; 1274 questionnaires were returned (35.2%).
Main outcome measures: Primary outcome variables were the Tooth Fairy’s visit after tooth loss and the amount of money given in case of a visit. Child- and parent-related variables were assessed as predictors of the main outcomes.
Results: Most parents (71.0%) reported that the Tooth Fairy visited their child. She usually exchanged the lost tooth for money (55.8% of visits) or placed money next to the tooth (40.7%); rarely did she take the tooth without pecuniary substitution. The Tooth Fairy left an average of 7.20 Swiss francs (approximately AU$9.45). The Tooth Fairy favoured visiting for the teeth of older children (odds ratio [OR], per year, 1.87; 95% CI, 1.09–3.21), of boys (OR, 2.65; 95% CI, 1.09–6.42), and of children who believed in her (OR, 4.12; 95% CI, 1.77–9.64). The amount of money was influenced by maternal, but not paternal socio-demographic factors, including level of education (OR, per level, 0.78; 95% CI, 0.66–0.92) and country of origin (OR, Western countries v non-Western countries, 2.35; 95% CI, 1.20–4.62).
Conclusions: The Tooth Fairy does not visit all children after tooth loss, displaying clear preferences in her choice of business partners. The odds of a visit are dramatically increased if she is believed in, and the value of a deciduous tooth is influenced by socio-demographic factors.
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His gravelly voice became one of the successful politician’s most defining features
Neville Kenneth Wran was the colourful and charismatic Premier of New South Wales from 1976 to 1986. He was widely respected for his quick wit, engaging informality, and committed representation of blue collar voters. The youngest of eight siblings, he was born in 1926 and raised in the Sydney suburb of Balmain, then a working class stronghold of the Australian Labor Party1 (Box 1).
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The planet will continue to revolve in the face of declining ecosystem health and diversity, but how will the human species fare in 20, or 200, years? Is there a health framework to resist the free market call to relentless expansion, economic growth and profit? What is our role as doctors in advocating for the voiceless, future inhabitants of this planet?
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In multicultural Australia, whatever your religious beliefs or cultural background, we celebrate together the summer holiday period and our shared values of family and community. On behalf of the entire MJA team, we welcome you to the 2017 Christmas issue of the Journal, a tradition in which we strive to amuse and entertain our readers over the holiday season.
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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.