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In January 2023, the Science and Security Board of the Bulletin of the Atomic Scientists moved the hands of the Doomsday Clock forward to 90 s before midnight, reflecting the growing risk of nuclear war.1 In August 2022, the UN Secretary‐General António Guterres warned that the world is now in “a time of nuclear danger not seen since the height of the Cold War”.2 The danger has been underlined by growing tensions between many nuclear armed states.1,3 As editors of health and medical journals worldwide, we call on health professionals to alert the public and our leaders to this major danger to public health and the essential life support systems of the planet — and urge action to prevent it.
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Virginia Barbour is an unpaid committee member of Wildlife Queensland. Kirsten Bibbins‐Domingo is a full‐time employee of the American Medical Association, working as the Editor‐in‐Chief of JAMA and the JAMA Network. Marcel Olde Rikkert has received research grants from the Dutch Research Council (NOW; grant no. COMPL.21COV.001) and the Netherlands Organisation for Health Research and Development (ZonMw; grant no. 09120012010063), and is chair of the Dutch guideline committee on cognitive impairments and dementia. Andy Haines is Principal Investigator for the Pathfinder Initiative 2020–2025, co‐investigator of the Sustainable and Healthy Food Systems research program 2017–2023, and co‐investigator with Complex Urban Systems for Sustainability and Health (CUSSH) 2017–2023, all funded by the Wellcome Trust, with additional funding from the Oak Foundation for the Pathfinder Initiative; has received royalties or licences from Cambridge University Press for the co‐authored book Planetary Health; has received consulting fees paid to his institution as senior advisor on climate and health, Wellcome Trust; and has received travel support related to the World Health Organization and the Human Frontiers Science Program. He has also had unpaid roles as a member of the cool roofs trial steering committee, Nouna Research Centre, Burkina Faso/University of Heidelberg; co‐chair of the International Advisory Committee, NIHR CLEAN‐Air (Africa) Global Health Research Unit; member of the Independent Advisory Group, Collaboration for the Establishment of an African Population Cohort Consortium (CE‐APCC); co‐chair of the InterAcademy Partnership, Climate Change and Health working group; and co‐chair of the Academy of Medical Sciences/Royal Society working group on “A healthy future: tackling climate change mitigation and human health together”. Ira Helfand reports honoraria for several speaking engagements, all donated to Back from the Brink, International Physicians for the Prevention of Nuclear War, or Physicians for Social Responsibility; travel and lodging support for attendance at the World Summit of Nobel Peace Laureates and the World Congress on Public Health; and lodging support for the UN Human Rights Youth Summit. He also reports unpaid membership of the board of International Physicians for the Prevention of Nuclear War, the International Steering Group of the International Campaign to Abolish Nuclear Weapons, the board of Physicians for Social Responsibility, and the Steering Committee of Back from the Brink; and has been a Trustee for Phillips Exeter Academy. Tilman Ruff reports consulting fees as part of a contract with the Institute for Energy and Environmental Research (USA) for papers addressing the health and environmental consequences of nuclear testing in multiple locations including Australia, French Polynesia, central Pacific and China; honoraria from the Chosunilbo media group in South Korea for a lecture on nuclear weapons at the Asian Leadership Conference in Seoul and from Gangwon Province for contributions to the JeongSeon Forum, and honoraria for nuclear weapons presentations from Hyogo Medical Practitioners Association (Japan), Peace Boat (Japan) and the University of Sydney; and payment for testimony as an expert witness on radiation and health for Environmental Justice Australia acting for Mine‐Free Glenaladale regarding the proposed Fingerboards mineral sands mine to the Victorian Government Fingerboards Inquiry and Advisory Committee. He also reports membership of the RV3 Rotavirus Vaccine Scientific Advisory Committee at Murdoch Children's Research Institute/Royal Children's Hospital, Melbourne; the Committee of the International Campaign to Abolish Nuclear Weapons Australia; the Internet Peace Prize Award Committee; the International Humanitarian Law Advisory Committee of the Australian Red Cross; the board of the Initiative for Peacebuilding at the Faculty of Arts, University of Melbourne; the board of International Physicians for the Prevention of Nuclear War; co‐presidency of the International Physicians for the Prevention of Nuclear War; and is an Honorary Principal Fellow at the Melbourne School of Population and Global Health, University of Melbourne. Paul Yonga was Principal Investigator for a COVID‐19 antiviral clinical trial funded by Atea Pharmaceuticals, for which he received no payments; has received honoraria from bioMérieux and Pfizer Pharmaceuticals for lectures, presentations and educational events; has participated on an advisory board for Pfizer Pharmaceuticals; and is a member of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) antimicrobial stewardship study group executive committee and a member of the ESCMID clinical practice guideline panel on vaccinations in immunocompromised hosts. Chris Zielinski reports fees from International Physicians for the Prevention of Nuclear War as Senior Advisor on the international journals project. All authors were paid by their respective employers.
This Comment is being published simultaneously in multiple journals. For the full list of journals see: https://www.bmj.com/content/full‐list‐authors‐and‐signatories‐nuclear‐risk‐editorial‐august‐2023.
Insomnia, obstructive sleep apnoea, and restless legs syndrome are the most frequent sleep disorders in Australia, together affecting almost half of all middle‐aged people.1 These conditions cost the Australian economy an estimated $11 billion per year in lost work productivity, comprising both absenteeism (absence from work) and presenteeism (people present at work but not fully functional).2 Less is known about the impact of sleep disorders on productivity in younger adults. The study by Reynolds and colleagues in this issue of the Journal3 fills an important gap in understanding how sleep disorders affect the productivity of young working adults.
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Correspondence: alan.young@easternhealth.org.au
No relevant disclosures.
The National Clinical Evidence Taskforce (NCET) established coronavirus disease 2019 (COVID‐19) drug treatment guidelines in March 2020 to provide clinicians with living evidence‐based recommendations for the care of patients with COVID‐19. These guidelines have been widely used and have informed practice in Australia and beyond. However, there are limitations to the available evidence, and, as the COVID‐19 pandemic has progressed, the NCET has had to address a number of challenges. This perspective article discusses these limitations and challenges and the strategies developed to ensure that the guidelines remain relevant and useful for clinicians (Box).
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Correspondence: tari.turner@monash.edu
Open access:
Open access publishing facilitated by Monash University, as part of the Wiley ‐ Monash University agreement via the Council of Australian University Librarians.
The National COVID‐19 Clinical Evidence Taskforce is funded by the Australian Government Department of Health and Aged Care, the Victorian Department of Health and Human Services, the Ian Potter Foundation and the Walter Thomas Cottman Endowment Fund (managed by Equity Trustees), and the Lord Mayors’ Charitable Foundation. We thank all members of the National COVID‐19 Clinical Evidence Taskforce for their contributions to the work described in this article, and acknowledge the Taskforce member organisations and our partners.
All authors are members of the National Clinical Evidence Taskforce. No personal payments have been received by any authors.
Objectives: To assess Australian hospital utilisation, 1993–2020, with a focus on use by people aged 75 years or more.
Design: Review of Australian Institute of Health and Welfare (AIHW) hospital utilisation data.
Setting, participants: Tertiary data from all Australian public and private hospitals for the financial years 1993–94 to 2019–20.
Main outcome measures: Numbers and population‐based rates of hospital separations and bed utilisation (bed‐days) (all and multiple day admissions) and mean hospital length of day (multiple day admissions), overall and by age group (under 65 years, 65–74 years, 75 years or more).
Results: Between 1993–94 and 2019–20, the Australian population grew by 44%; the number of people aged 75 years or more increased from 4.6% to 6.9% of the population. The annual number of hospital separations increased from 4.61 million to 11.33 million (146% increase); the annual hospital separation rate increased from 261 to 435 per 1000 people (66% increase), most markedly for people aged 75 years or more (from 745 to 1441 per 1000 people; 94% increase). Total bed utilisation increased from 21.0 million to 29.9 million bed‐days (42% increase), but the bed utilisation rate did not change markedly (1993–94, 1192 bed‐days per 1000 people; 2019–20, 1179 bed‐days per 1000 people), primarily because the mean hospital length of stay for multiple day admissions declined from 6.6 days to 5.4 days; for people aged 75 years or more it declined from 12.2 to 7.1 days. However, declines in stay length have slowed markedly since 2017–18. Total bed utilisation was 16.8% lower than projected from 1993–94 rates, and was 37.3% lower for people aged 75 years or more.
Conclusion: Hospital bed utilisation rates declined although admission rates increased during 1993–94 to 2019–20; the proportion of beds occupied by people aged 75 years or more increased slightly during this period. Containing hospital costs by limiting bed availability and reducing length of stay may no longer be a viable strategy.
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No relevant disclosures.
Until recently, the management of people with inherited retinal diseases (IRDs) was largely limited to referral for vision aids and registration as being legally blind. This situation is now rapidly changing in the disciplines of ophthalmology and clinical genetics, largely due to the emergence of gene‐based therapies that halt disease progression. IRDs comprise a group of diverse disorders that includes retinitis pigmentosa, Stargardt disease, choroideraemia, Best disease, congenital stationary night blindness, achromatopsia, Leber congenital amaurosis, and similar conditions. Four decades of research have led to the identification of pathogenic variants in more than 300 IRD‐causing genes. While the individual conditions and gene variants are rare, together they affect up to one in 1000 people in Australia, or as many as 25 000 people; IRDs are the leading cause of blindness in working age adults.1,2 The loss of central or peripheral vision, profound nyctalopia, and debilitating photophobia have a significant impact on daily activities and consequently the independence of people with these conditions. For example, IRDs can affect navigation, facial recognition, and driving: all significant for quality of life.3
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Fred Chen receives consultancy fees from Novartis, PYC Therapeutics, and Janssen.
The burden of asthma for patients and doctors can be reduced through simple evidence‐based approaches to care and self‐management
In 2017–18, there were almost 40 000 hospitalisations for asthma, up to 80% of which could have been avoided with better asthma care and resources in the community.11,12,13 In 2020–21, the numbers were reduced, paradoxically thanks to the COVID‐19 pandemic.14 However, children aged under 15 years still constitute the largest proportion of people presenting to emergency departments in Australia with a respiratory condition, and asthma is the leading preventable cause of these presentations.15,16,17 Respiratory conditions generally account for the highest proportion of emergency department presentations in relation to other disease systems, and around one‐third of these people are admitted to hospital.5 These presentations and admissions for asthma comprise a large group of patients with a readily treatable disease.12 Further, there is a tenfold variation in hospitalisation rate between the highest and the lowest socio‐economic regions, and people with asthma in low income settings and in rural Australia are doing worst of all.5,18 This is not inevitable — much of it can be prevented by simple evidence‐based approaches to asthma care, including assessing triggers, performing spirometry, devising a written action plan, and checking device use and adherence.
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Christine Jenkins has received honoraria from AstraZeneca, GSK, Boehringer Ingelheim, Novartis and Chiesi for educational and advisory activities. Philip Bardin has received honoraria from GSK, AstraZeneca and Sanofi for educational activities. John Blakey has received honoraria from AstraZeneca, Boehringer Ingelheim, Chiesi, GSK and Sanofi for educational activities. Kerry Hancock has received honoraria from AstraZeneca, Chiesi, Novartis, BI Arterial Education, Asthma Australia and Spirometry Learning Australia for educational activities. Peter Gibson has received honoraria from AstraZeneca, GSK, Novartis and Chiesi for educational activities. Vanessa McDonald has received honoraria from GSK, AstraZeneca, Novartis, Boehringer Ingelheim and Menarini for educational and advisory activities.
The direct and indirect costs of cancer care are rising and can influence treatment decisions and outcomes for patients.1 Several patient‐level characteristics are risk factors for financial burden, including lower age, chemotherapy, and poorer general health.2 Health professionals have a role in providing information, resources, and support to mitigate financial distress for patients.3
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jefford@unimelb.edu.au, michael.jefford@petermac.org
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Open access publishing facilitated by The University of Melbourne, as part of the Wiley – The University of Melbourne agreement via the Council of Australian University Librarians.
We acknowledge the Victorian Department of Health as the source of the Victorian Health Experience Survey data. We also thank all participants who completed the survey.
No relevant disclosures.
Introduction: Long term opioids are commonly prescribed to manage pain. Dose reduction or discontinuation (deprescribing) can be challenging, even when the potential harms of continuation outweigh the perceived benefits. The
Main recommendations: Eleven recommendations provide advice about when, how and for whom opioid deprescribing should be considered, while noting the need to consider each person's goals, values and preferences. The recommendations aim to achieve:
Changes in management as a result of these guidelines: To our knowledge, these are the first evidence‐based guidelines for opioid deprescribing. The recommendations intend to facilitate safe and effective deprescribing to improve the quality of care for persons taking opioids for pain.
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Aili Langford was funded by a Research Training Program Scholarship and Supplementary Scholarship from the University of Sydney throughout her PhD candidature. The research team were awarded a 2019 Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney Research Support Grant. Christine Lin is funded by a National Health and Medical Research Council (NHMRC) Investigator Grant (1193939). Danijela Gnjidic is funded by the NHMRC Dementia Leadership Fellowship (1136849). Emily Reeve is funded by an NHMRC Investigator Grant (1195460). Suzanne Nielsen is funded by an NHMRC Career Development Fellowship (1163961). The funding bodies/sources had no role in the planning, writing or publication of this work.
We acknowledge Jack Collins (Postdoctoral Research Associate, University of Sydney) and Benita Suckling (Master of Philosophy Candidate, University of Sydney, and Pharmacist at Caboolture Hospital, Queensland Health, Brisbane) for their contributions to the synthesis and appraisal of evidence informing this guideline. We also acknowledge Steven Agiasotis (undergraduate pharmacy student, University of Sydney) for his contribution to the development of the guideline algorithm.
Emily Reeve receives royalties from UpToDate (Wolters Kluwer) for writing a chapter on deprescribing. Suzanne Nielsen has received untied educational grants from Seqirus to study prescription opioid poisoning, and was a named investigator on a buprenorphine depot implementation trial funded by Indivior, both unrelated to this work. Simon Holliday was provided an honorarium by Indivior for two presentations unrelated to this work.
Objectives: To assess the effectiveness of a brief alcohol intervention for improving awareness of alcohol as a breast cancer risk factor, improving alcohol literacy, and reducing alcohol consumption by women attending routine breast screening.
Design: Single‐site, double‐blinded randomised controlled trial.
Setting: Maroondah BreastScreen (Eastern Health, Melbourne), part of the national breast cancer screening program.
Participants: Women aged 40 years or more, with or without a history of breast cancer and reporting any alcohol consumption, who attended the clinic for routine mammography during 5 February – 27 August 2021.
Intervention: Active arm: animation including brief alcohol intervention (four minutes) and lifestyle health promotion (three minutes). Control arm: lifestyle health promotion only.
Major outcome measure: Change in proportion of women who identified alcohol use as a clear risk factor for breast cancer (scaled response measure).
Results: The mean age of the 557 participants was 60.3 years (standard deviation, 7.7 years; range, 40–87 years); 455 had recently consumed alcohol (82%). The proportions of participants aware that alcohol use increased the risk of breast cancer were larger at four weeks than at baseline for both the active intervention (65%
Conclusion: A tailored brief alcohol intervention for women attending breast screening was effective for improving awareness of the increased breast cancer risk associated with alcohol use and alcohol literacy more broadly. Such interventions are particularly important given the rising prevalence of risky drinking among middle‐aged and older women and evidence that even very light alcohol consumption increases breast cancer risk.
Registration: ClinicalTrials.gov, NCT04715516 (prospective; 20 January 2021).
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This study was supported by research grants from VicHealth and the Eastern Health Foundation. The funders had no role in any part of this study. We thank BreastScreen Victoria for their support. We thank the staff of Maroondah BreastScreen for supporting this project at their clinic, and we gratefully acknowledge all Maroondah BreastScreen clients who participated in the trial. We thank Erin Flatters (Jumbla Animation Studios) for producing the intervention animations. We thank Alun Pope (Analytical Insight) for his contribution to data preparation and statistical analyses.
Dan Lubman, Victoria Manning, Robin Bell, and Jasmin Grigg have received grants from the National Health and Medical Research Council. Dan Lubman, Victoria Manning and Robin Bell have received grants from the Medical Research Future Fund. Dan Lubman, Victoria Manning, and Jasmin Grigg have received funding from Shades of Pink and the Victorian Department of Health. Dan Lubman and Victoria Manning have received grants from the HCF Research Foundation, the Alcohol and Drug Research Innovation Agenda, the Alcohol and Drug Foundation, the Eastern Health Foundation, the Victorian Responsible Gambling Foundation, and the National Centre for Clinical Research on Emerging Drugs. Dan Lubman has received grants from Google, the Australian Research Council, VicHealth, and the Australian Department of Health and Aged Care. Victoria Manning has received funding from the Transport Accident Commission (Victoria). Jasmin Grigg has received funding from the Victorian Department of Transport and Planning. Dan Lubman is supported by a National Health and Medical Research Council Leadership Fellowship. Isabelle Volpe is supported by an Australian Government Research Training Program stipend.
Summary