Volume 207 Issue 2

The availability of new antiviral agents opens the way for increasing GP involvement in the management of hepatitis C

Mieke L van Driel · David Lim · Paul J Clark

Learning from the past to ensure effectiveness, efficiency and equity in primary health care

Sara Javanparast · Fran Baum · Toby Freeman · Ronald Labonte · Anna M Ziersch · Michael R Kidd · Tamara Mackean

The available evidence from the past 20 years of government interventions can inform future priorities

Lucie K Walters · Matthew R McGrail · Dean B Carson · Belinda G O'Sullivan · Deborah J Russell · Roger P Strasser · Richard B Hays · Max Kamien

Iron polymaltose was administered via rapid infusion

Martin L Canning · Kenneth A Gilmore

Lessons from practice•Diagnosis of adult-onset asthma should be made with caution.•The presence of an inhaled foreign body in the upper airway may be misdiagnosed as asthma.•Direct visualisation with an endoscope is required to exclude the presence of a foreign body.

Amy SM Wong · Bing Mei Teh · Glen Burgess · Michael CS Ho

A bedside test to assist clinicians in diagnosing peripheral arterial disease

Nicole M Organ · Catherine Harrison

It must be — as an essential component of the response to the antimicrobial drug resistance problem

Martin Gulliford · Mark Ashworth

Explicit training in appropriate decision making about pathology test ordering should be provided early

Justin J Beilby

Antibiotic prescribing in Australian general practice could be substantially reduced

Amanda R McCullough · Allan J Pollack · Malene Plejdrup Hansen · Paul P Glasziou · David FM Looke · Helena C Britt · Christopher B Del Mar

Good pathology test ordering habits need to be instilled early in a GP’s clinical career

Parker J Magin · Amanda Tapley · Simon Morgan · Kim Henderson · Elizabeth G Holliday · Andrew R Davey · Jean Ball · Nigel F Catzikiris · Katie J Mulquiney · Mieke L van Driel

Improving the quality, continuity, and cultural appropriateness of care is also important

Megan Carroll · Matthew J Spittal · Anna R Kemp-Casey · Nicholas G Lennox · David B Preen · Georgina Sutherland · Stuart A Kinner

Iron deficiency and iron deficiency anaemia remain prevalent in Australia

Michael SY Low · George Grigoriadis

To the Editor: In Adelaide, which comprises 78% of the population of South Australia, municipal wastewater has been subject to bimonthly analysis since 2009 to measure trends in substance use. Beginning in October 2015, there was a precipitous decrease in the detection of oxycodone residues in wastewater samples (Box). This decrease was counter to the long term trend of increasing amounts of this opioid in previous samples. Prescribing data show a continuing increase in the use of prescription opioid analgesics (POAs), including oxycodone, nationally and in SA, during the period between 1992 and 2011.1 There is a strong relationship between the amount of POAs used in a community and the amount of harm from opioid dependence and overdose.1 The cause of this regional trend change in oxycodone use has not been established. On 1 July 2015, there were some significant changes in the regulation of work injuries in SA which led to a decrease in the number of complex long term claimants, and there was also a similar change in South Australian motor vehicle injury regulation in July 2013. Complex injury claims are strongly correlated with POA use;2 however, the role of these factors is highly speculative and there may be many other factors that contributed to the results. The methods used for the bimonthly wastewater analysis in Adelaide have been published before,3 and another group used this process to report changes in population methamphetamine use in Queensland.4 From October 2015, there was a change in the established temporal trend for oxycodone residues detected in Adelaide wastewater (Box). However, over the same period, there is no such trend change for national Pharmaceutical Benefits Scheme (PBS) and Repatriation PBS data for the number of oxycodone prescriptions dispensed (not total doses),5 or for Adelaide wastewater residues of methadone, which is predominantly dispensed for treatment of severe opioid use disorders via a specific program. A limitation of our investigations was that no regional oxycodone prescription or wastewater data from other jurisdictions were available for comparison. Nonetheless, our findings suggest that wastewater analysis could potentially be used to rapidly monitor changes in substance use on a regional basis. Box – Oxycodone and methadone residue in Adelaide wastewater compared with national data for the total number of oxycodone prescriptions supplied, December 2011 – February 20175 PBS = Pharmaceutical Benefits Scheme. RPBS = Repatriation Pharmaceutical Benefits Scheme.

Philip Crowley · Jason M White · Benjamin J Tscharke · Cobus Gerber

To the Editor:We read with interest the excellent review by Scott and colleagues1 on the contribution of sarcopenia to type 2 diabetes in the ageing Australian population. In a prospective Australian cohort of community-dwelling men, we recently found that muscle grip strength and muscle quality, but not muscle mass, were associated with incident type 2 diabetes at 5 years follow-up.2 These associations were not mediated by serum interleukin 6 or tumour necrosis alpha. As we did not examine sarcopenia, nor appendicular lean mass adjusted for body mass index (ALM-BMI), we have undertaken further analysis in 1180 participants with valid sarcopenia data. Their mean age was 56.9 years (standard deviation [SD] ± 10.9), mean ALM-BMI at baseline was 0.950 (SD ± 0.135) and mean peak hand grip strength at baseline was 48.7 kg (SD ± 9.9 kg). At 5 years follow-up, incident type 2 diabetes occurred in 119 participants (10.1%). Baseline ALM-BMI of less than 0.789 occurred in 9.2% of patients (n = 109) and baseline grip strength of less than 26 kg occurred in 1.4% of patients (n = 16), thus only six participants (0.5%) had sarcopenia as defined by the Foundation for the National Institutes of Health Biomarkers Consortium Sarcopenia Project (both ALM-BMI < 0.789 and peak hand grip strength < 26 kg).3 Hence, in our middle-aged Australian cohort of men, the prevalence of sarcopenia was very low. Moreover, while there was an unadjusted association between baseline ALM-BMI of less than 0.789 and incident type 2 diabetes (odds ratio [OR] 2.54; 95% CI, 1.49–4.17; P < 0.001), this attenuated to non-significance after adjustment for age, subcohort, income, fasting plasma glucose, physical activity, family history of diabetes, triglycerides and hypertension (OR 1.73; 95% CI, 0.95–3.05; P = 0.06). However, when analysing ALM-BMI as a continuous variable, the adjusted association was significant (OR per 0.1 unit decrease: 1.33; 95% CI, 1.13–1.58; P < 0.001). Overt sarcopenia may not have a large contribution to type 2 diabetes in community-dwelling Australians. Rather, reduction of skeletal muscle strength, ALM-BMI and muscle quality across the spectrum of healthy values may have greater population level significance. Our previous population-attributable fraction calculations suggest that a substantial proportion of incident type 2 diabetes may be prevented if muscle strength in the Australian community was generally increased.2

Joule J Li · Jonathan W Newbury · Robert J Adams

In reply

David Scott · Barbora de Courten · Peter R Ebeling

Editor’s note: The Lancet recently published an important Australian randomised controlled trial of robotic and open prostatectomy. We publish the following non-commissioned correspondence by Hutchison and colleagues together with an invited response from the corresponding author of the trial, Robert Gardiner, because of the relevance of the debate to Australian health care. To the Editor: Robotic prostatectomy took off quickly, despite the cost. In Australia, most prostatectomies are now done with a robot that costs almost $10 000 in capital and maintenance per procedure, or between $442 and $3548 more than an open prostatectomy.1 The robotic option was meant to reduce side effects relating to impotence and incontinence; however, preliminary findings from the world’s first randomised controlled trial suggest that this is not the case.2 Uptake of innovative surgery tends to outpace evidence because it is hard to design and run randomised studies. In addition, placebo surgery is rare and controversial, and recruitment is challenging, as surgeons and patients often prefer one option. Trial results may also be difficult to interpret: if the same surgeon performs both operations, they may be better at one; or if different surgeons operate, one may be superior.3 Australia is not immune to these challenges, despite local initiatives to improve quality of care4 and evaluate the benefits of the robotic procedure.5 The industry understands this. Intuitive Surgical aggressively marketed its robot while the jury was still out on its comparative benefits. Celebrity stories have also driven demand; for instance, radio personality Alan Jones has been an outspoken advocate.6 But even when evidence commends a surgical innovation, introducing it to the public health care system may create or exacerbate inequity. Suppose that the robot, or some successor, eventually proves superior to alternatives. Expensive equipment and difficult procedures require high patient throughput to justify the costs and maintain surgeons’ skills, so they tend to be concentrated in the biggest, busiest hospitals. Therefore, patients in regional areas are often expected to travel for treatment, with little or no financial support; and the barrier is even higher for people who do not have the social and economic resources to get themselves to a big city hospital.7 We should resist the hype of a new technology and wait for good evidence before expending scarce health care dollars. This will sometimes mean lagging behind other countries and saying no to patients. However, it will also mean safeguarding patients and the public purse from innovations that turn out to be no better, or maybe worse, than existing options. Moreover, when a new technology is introduced, we should also fund the supports that people need to access it.

Katrina Hutchison · Drew Carter · Jane Johnson

In reply

Mark Frydenberg · Robert (Frank) A Gardiner

The best general practitioners in the country have been nominated and chosen, leading up to the GP17 conference later in 2017

Cate Swannell

A group of doctors was honoured at the recent Rural Doctors Association of Queensland 27th Annual Conference in Townsville. Two James Cook University graduates were the joint inaugural recipients of the Denis Lennox Medal for Outstanding Rural Generalist Registrar. Mount Isa GP Dr Marjad Page, a proud Kalkadoon, Waanyi and Ganggalidda man from the Mt Isa region, started his registrar training in 2010 and is a Fellow of the Australian College of Rural and Remote Medicine (ACRRM). He completed advanced skills training in obstetrics and gynaecology and is a qualified GP anaesthetist. He has worked in public, private and community settings. Gladstone GP Dr Claudia Collins, also a Fellow of ACRRM, started her registrar training in 2009. She has worked in Rockhampton and Longreach and now is based in Gladstone working with Nhulundu Health Service, completing a second advanced qualification in Indigenous health following on from her qualifications in obstetrics. Dr Collins, whose motto for the care she provides is “strong mums, healthy bubs”, is a member of the statewide lead clinician’s group formed by Queensland Aboriginal and Islander Health Council to improve Indigenous health service provision and Indigenous health outcomes in Queensland. University of Queensland alumnus Dr Richard Tan was named as a “Legend of the Bush” for his almost 50 years of practice in Biloela in central Queensland, during which he has performed approximately 10 000 operations and delivered more than 3000 babies. Another UQ graduate, Dr David Rimmer, was honoured with a Meritorious Service Award for lasting influence on improved health care models for people living in the bush – particularly those living in the far west of Queensland. Dr Rimmer began his medical training in Brisbane and then moved to Victoria to work at Wangaratta and Melbourne Children’s hospitals. Following his interstate service, he completed his RACGP qualification in Toowoomba, before joining his brother Robert in a new Toowoomba general practice, then moving into emergency medicine at the Mater Hospital in Brisbane. He worked at Kowanyama in Cape York for several years before returning to the Wesley in Brisbane to continue emergency medicine, while filling relieving shifts for the Royal Flying Doctor Service. His last posting was ground staff at Longreach. There his friend and former Toowoomba GP, Dr Dilip Dhupelia, recruited him to the position of executive director of medical services for the Central West Hospital and Health Service. Husband and wife team Dr Matt Masel and Dr Sue Masel (both University of Queensland), also received Meritorious Service Awards for their work in Goondiwindi, both in private practice and in the reinvigoration of maternity services at the local hospital. Winnie Yum, a medical student at UQ, was named the Academic Winner, Tamara Hall was named “Backbone of the Bush”, and Alison Fairleigh was awarded the David Horn Memorial Medal http://conference.rdaq.com.au/rdaq-2017-award-winners-announcement/ Three medical researchers from Griffith University have won Vice Chancellor’s Research Excellence Awards. The award for excellence for an individual mid-career or senior researcher went to Professor Vicky Avery, from the Griffith Institute for Drug Discovery. She heads the Griffith University Drug Discovery Program for the CRC for Cancer Therapeutics (CTx) and the Discovery Biology team. Professor Avery was recognised for her outstanding research in drug discovery over the past 18 years. Her vision is to promote world class drug discovery, utilising advanced image-based platforms, ultimately impacting on access to quality therapeutics for all. She aims to address fundamental basic research questions, to better understand the biology and to facilitate drug discovery in the search for novel lead molecules, particularly where drug resistance is apparent or the disease is neglected. Her objective is to improve and expedite drug discovery, and to endeavour to provide platforms where currently they are non-existent, limited or of poor quality. Professor Cordia Chu from the Centre for Environment and Population Health, a part of Griffith’s Menzies Health Institute Queensland, was recognised for her distinguished record in research supervision. Since 1996, Professor Chu has supervised to completion 34 PhDs, three MPhils, six honours and more than 45 Masters theses. Professor Chu has developed research expertise in areas integrating environment and health such as healthy cities, workplace health and safety risk management, gender and reproductive health, migrant and vulnerable populations, population and settings-based health promotion, climate change adaptation for health. The Laboratory for Vaccines for the Developing World team led by Professor Michael Good from the Institute for Glycomics won the award for Research Group/Team. Professor Good’s team’s outstanding work led to a major translational outcome for the Institute in 2016, with the signing of a significant licensing agreement with major international vaccine manufacturing company, Olymvax Biopharmaceuticals in China. Their needle-free vaccine targets Streptococcus A infections, the cause of strep throat and rheumatic heart disease. The lab’s team of more than 10 researchers could potentially see a vaccine in the market within the next 6-8 years. https://app.secure.griffith.edu.au/news/2017/06/14/griffith-research-excellence-honoured-3/ Providing the first community-based post-traumatic stress disorder (PTSD) treatment for war veterans is just one of the achievements of Griffith University’s Professor David Crompton, the latest recipient of the Margaret Tobin Award. Named in honour of the late Dr Margaret Tobin, the honour is awarded to the Royal Australian New Zealand College of Psychiatrists (RANZCP) Fellow who has made the most significant contribution to administrative psychiatry in the region over the preceding 5 years. Professor Crompton is the new director of Griffith University’s Australian Institute for Suicide Research and Prevention (AISRAP) and also the executive director of Metro South Addiction and Mental Health Services. In 1998, Professor Crompton led the development of the first community treatment program in Strathpine for veterans with PTSD, mental health issues and substance abuse. This led into community-based treatment for patients with work-related trauma. Both continue to this day in a community setting attached to Toowong Private Hospital, in Brisbane. The establishment of an effective means of identifying adults and older people affected by the cyclones and floods of 2010-11 was also the work of a team led by Professor Crompton. Operating Queensland’s Mental Health Disaster Program through the Department of Health, he set up a successful program which ran in community centres and GP practices across the state. Over the last 5 years Metro South Addiction and Mental Health Services has also changed with the formation of the Hospital and Health Service and the implementation of clinical programs guided by research and learning. The Service now is an active participant in clinical research with staff enrolled in PhDs and conjoint positions with Griffith University, QUT and the University of Queensland. https://app.secure.griffith.edu.au/news/2017/05/16/griffith-psychiatrist-honoured-with-prestigious-award/ One of the highest awards in the field of perfusion in heart and lung surgery, the American Society of Extracorporeal Technology’s John H Gibbon Jr Award, has been presented to Flinders Medical Centre and Flinders University Professor Robert Baker. The award is presented for contributions to the science and practice of extracorporeal circulation, a specialist field of medicine involving maintaining the circulation of blood and oxygen through the body during cardiac, cardiothoracic and other surgeries. Professor Baker is the first Australian-based clinician to be awarded this honour. Professor Baker is the Director of Clinical Perfusion and Cardiac Surgery Research at Flinders, and was a foundation member of the team to commence cardiac surgery at Flinders in 1992. The international perfusion award was established in 1974 and recipients include innovators and leaders in the field of cardiac surgery such as Dr Michael DeBakey and Dr Denton Cooley. The award is named after John H Gibbon Jr, an American cardiac surgeon who invented the heart-lung machine. Professor Baker chairs both the International Consortium for Evidence-Based Perfusion and the Australian and New Zealand Collaborative Perfusion Registry. http://news.flinders.edu.au/blog/2017/06/05/heart-stopper-award-for-prof-baker/