Volume 210 Issue 11

A 26- year- old man presented to the (ED) overnight with severe and disabling abdominal pain

David J Holland · Michael J Holland

A 59- year- old woman with carbimazolerefractory Graves disease presented with fever and extensive necrotising rash 2 weeks after commencing propylthiouracil therapy

Brian Lam · Alexander Yuile · Suran L Fernando

Teens and their doctors. The story of the development of adolescent medicine

Michelle M Telfer

N arrowly targeting single risk factors will not reduce gaps in injury burden and other health outcomes

Geoffrey J Dobb · Kwok M Ho

Objectives: To investigate the admission characteristics and hospital outcomes for Indigenous and non‐Indigenous patients admitted to intensive units (ICUs) after major trauma. Design, setting: Retrospective analysis of Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database data from 92 Australian ICUs for the 6‐year period, 2010–2015. Participants: Patients older than 17 years of age admitted to public hospital ICUs with a primary diagnosis of trauma. Main outcome measures: ICU and overall hospital lengths of stay, hospital discharge destination, and ICU and overall hospital mortality rates for Indigenous and non‐Indigenous patients. Results: 23 804 people were admitted to Australian public hospital ICUs after major trauma; 1754 (7.4%) were Indigenous Australians. The population‐standardised incidence of admissions was consistently higher for Indigenous Australians than for non‐Indigenous Australians (847 per million v 251 per million population; incidence ratio, 3.37; 95% CI, 3.19–3.57). Overall hospital mortality rates were similar for Indigenous and non‐Indigenous patients (adjusted odds ratio [aOR], 1.04; 95% CI, 0.82–1.31). Indigenous patients were more likely than non‐Indigenous patients to be discharged to another hospital (non‐Indigenous v Indigenous: aOR, 0.84; 95% CI, 0.72–0.96) less likely to be discharged home (non‐Indigenous v Indigenous: aOR, 1.17; 95% CI, 1.04–1.31). Conclusion: The population rate of trauma‐related ICU admissions was substantially higher for Indigenous than non‐Indigenous patients, but hospital mortality rates after ICU admission were similar. Indigenous patients were more likely to be discharged to a another hospital and less likely to be discharged home than non‐Indigenous patients.

Fraser Magee · Anthony Wilson · Michael J Bailey · David Pilcher · Paul J Secombe · Paul Young · Rinaldo Bellomo

Australian reference values provide benchmarks for assessing the impact of disease and treatment on Australians with cancer

Rebecca Mercieca‐Bebber · Daniel SJ Costa · Richard Norman · Monika Janda · David P Smith · Peter Grimison · Eva‐Marie Gamper · Madeleine T King

Early risk stratification is central to determining the need for further investigations

Jason Chan · Jonathan Hunter · Douglas Morel · Emma Ballard · David Brain · Alan Yan · Julia Hocking

These are the first Australasian recommendations for diagnosis and management of HIT, with a focus on locally available diagnostic assays and therapeutic options

Joanne Joseph · David Rabbolini · Anoop K Enjeti · Emmanuel Favaloro · Marie‐Christine Kopp · Simon McRae · Leonardo Pasalic · Chee Wee Tan · Christopher M Ward · Beng H Chong

The diagnosis of DVT requires a high index of suspicion because symptoms and signs are often non-specific

Paul C Kruger · John W Eikelboom · James D Douketis · Graeme J Hankey

To the Editor: Moynihan and colleagues1 make a good case for Australia responding to the complex challenge of reducing the overdiagnosis of clinical disease. However, this challenge should not lead to confusion with the early diagnosis of and the early intervention in preclinical disease, which are the mainstay of secondary prevention. While reducing diagnosis creep and expanding disease definitions are predominantly the realm of the specialist disciplines, primary care is uniquely placed to embrace preclinical disease diagnosis, increasing early detection and intervention, while specialists endorse reducing overdiagnosis, both collaborating in lowering long term costs to the health system. Preclinical disease and its impact are emerging as the logical next challenge. Prediabetes, for example, is almost always present before the onset of diabetes.2,3 Both the American Diabetes Association3 and Diabetes Australia4 have published recommendations on the diagnosis and screening for diabetes and prediabetes. The American Diabetes Association also leads the way in recommending that screening should be considered in children and adolescents who are overweight or obese and who have additional risk factors for diabetes.3 In 2015, the most comprehensive undertaking since Medicare's inception in the 1980s was established to consider how the more than 5700 items on the Medicare Benefits Schedule (MBS) could be aligned with contemporary clinical evidence and practice and improve health outcomes for patients with clinical disease (tertiary prevention).5 Although, the evidence base around early diagnosis and intervention is relatively recent, it is now opportune for the federal government to initiate a second tier to the MBS Review to consider new MBS items, where appropriate, for the early diagnosis of and early intervention in preclinical disease (secondary prevention). Further, this would align well with the new global awareness and endorsement of lifestyle medicine.6 Reversing the underdiagnosis of preclinical disease would be the perfect partner to reversing the overdiagnosis of clinical disease in delivering better health outcomes for patients, while reducing long term costs to the health system.

Eugen Molodysky

To the Editor: I read with interest the article by Moynihan and colleagues1 and commend the authors on their timely review of this important topic. While the article referred to research that had highlighted concerns about overdiagnosis in relation to several medical and surgical conditions, the only psychiatric condition mentioned was attention deficit/hyperactivity disorder. The authors referred to the problem of medicalisation as one of the possible drivers of overdiagnosis in one of the figures within the article, but not in the text of the article — medicalisation is the process by which non‐medical problems become defined and treated as disorders. In 2005, the medical expenditure on identified medicalised conditions in the United States was estimated to be about US$77 billion.2 Medicalisation in psychiatry has been a particular concern because of the problem created by ever‐expanding definitions of mental disorders and lowering of diagnostic thresholds.3 This has been well illustrated by the changes in the diagnostic criteria within the successive editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association, now in its fifth edition (DSM‐5). The effect of a change in the DSM diagnostic criteria was reported in 2001: changes from the third edition (DSM‐III) to the fourth edition (DSM‐IV), with an increase of the variety of stressors (events) considered capable of leading to post‐traumatic stress disorder (PTSD), led to a finding that 38% of DSM‐IV PTSD cases resulted from its wider definition.4 In the DSM‐5 the diagnostic criteria for PTSD have been further relaxed, so that “emotional reactions to the traumatic event” are no longer part of the diagnostic criteria. Another example of overdiagnosis in psychiatry is that of adjustment disorder. A 2008 article stated that there are “huge [numbers] of false‐positives for depressive and anxiety disorders because the context of symptoms is not taken into account,” and that the diagnosis of adjustment disorder “seems, by definition, ideally suited to apply to healthy people in dangerous and uncertain circumstances”.5 It is to be hoped that the 7th international Preventing Overdiagnosis conference in 2019 will include a session on overdiagnosis also in psychiatry.

George Mendelson

In reply

Raymond Moynihan · Alexandra L Barratt · Paul P Glasziou