Volume 210 Issue 8

Inflammatory arthritis has a significant impact on sex lifeResearchers from Curtin University have found that people with inflammatory arthritis are more likely to experience higher levels of sexual dysfunction in their intimate relationships. Arthritis affects one in six people in Australia, and it is projected that the number will rise to 5.4 million people by 2030. The research, published in Arthritis Care and Research, analysed 55 published research studies from Europe, America, Asia and Africa to better understand the impact of inflammatory arthritis on intimate relationships in both men and women. The authors found that people with inflammatory arthritis were more likely to experience pain and mobility restrictions during sexual intercourse, as well as psychological effects such as reduced self‐esteem, poor body image perception, and lower mood, which in turn impaired sexual function. For men with inflammatory arthritis, erectile dysfunction was the most significant problem, leading to additional frustration, stress, and a sense of emasculation. Negative body image, reduced desire for intercourse, and erectile dysfunction all contributed to an altered sense of sexuality in men and women. The authors suggested that partners who understood the disease better were more likely to try to strengthen their relationship, while those with no understanding experienced added fear and tension in the relationship. https://onlinelibrary.wiley.com/doi/abs/10.1002/acr.23857 Psychostimulants may play role in fatal strokes in young adultsResearchers from UNSW Sydney have found that psychostimulant use plays a major role in stroke deaths among people under 45. In a study published in the Journal of Forensic Sciences, the authors, from the National Drug and Alcohol Research Centre, found that nearly one‐fifth of 279 people aged 15–44 years who suffered a fatal stroke in Australia during 2009–2016 used psychostimulant drugs, and that in most cases there was evidence of psychostimulant consumption immediately before the fatal stroke. An estimated 76 million people worldwide use psychostimulants, including illicit drugs such as methamphetamine, cocaine, and 3,4‐methylenedioxymethamphetamine (MDMA), as well as prescription stimulants. In most cases of fatal stroke in young adults, methamphetamine was the implicated drug, and the median methamphetamine blood concentration was similar to that reported for methamphetamine‐related deaths in Australia in general, but fewer than half the deaths were attributed to methamphetamine toxicity alone, suggesting that high blood levels are not necessary for methamphetamine‐related stroke. Cases of haemorrhagic stroke were also documented that involved other illicit and licit psychostimulants, but medications for attention deficit hyperactivity disorder were not implicated in any deaths. Significantly, the anatomic location of the fatal stroke was different for psychostimulant users: the researchers found that they were more likely to suffer a stroke in the substance of the brain itself, rather than in the subarachnoid space around the brain. These types of strokes are far more likely to be fatal. https://onlinelibrary.wiley.com/doi/full/10.1111/1556-4029.14056

Cate Swannell

Lipid abnormalities are causally related to atherosclerotic cardiovascular disease; selected lipid interventions have been shown to improve this risk

Susannah Ahern · Ingrid Hopper · Erwin Loh

A preference for open peer review may reflect a historical, predominantly individualistic rather than collectivist cultural perspective

Jose Florencio F Lapeña · Peter L Munk · Aik Saw · Wilfred CG Peh

Brieger D, D'Souza M, Hyun K, et al. Intensive lipid‐lowering therapy in the 12 months after an acute coronary syndrome in Australia: an observational analysis. Med J Aust 2019; 210: 80‐85. https://doi.org/10.5694/mja2.12035 In the Research article above, the name of the third author was incorrect; her name is Karice Hyun. The change has been made online. ◆

A 26-year-old refugee from Myanmar was referred to the infectious diseases unit of an Australian teaching hospital

David WJ Griffin · G Khai Lin Huang · Philippe Lachapelle · Steven YC Tong · Siddhartha Mahanty

A 30-year-old woman was admitted for pancreatitis

Anthony Yao · Bob Wang

Being part of a network allows the clinician to think beyond the boundaries of their hospital

Peter J Hand

EPAs have a strong theoretical basis, can be used as assessment tools in a real world workplace based training environment

Nyoli Valentine · Jon Wignes · Jill Benson · Stephanie Clota · Lambert WT Schuwirth

Given the devastating consequences of TSCI, improved primary prevention strategies are needed

Ben Beck · Peter A Cameron · Sandra Braaf · Andrew Nunn · Mark C Fitzgerald · Rodney T Judson · Warwick J Teague · Alyse Lennox · James W Middleton · James E Harrison · Belinda J Gabbe

Reperfusion therapies for ischaemic stroke have transformed the prognosis for long term disability, but maximising patient benefit requires increased community recognition and faster treatment

Bruce CV Campbell

Due to the remarkable improvements in the diagnosis and management of myeloma over the past decade, we can look forward to regimens that will allow the eradication of residual disease and result in the cure of myeloma

Douglas E Joshua · Christian Bryant · Caroline Dix · John Gibson · Joy Ho

To the Editor: We note with interest the letter from Peisah and colleagues.1 A group of oft‐forgotten patients also affected by “no returns” policies is older people with mental illness. We have recent experience of a 72‐year‐old man with diagnoses of schizoaffective disorder and Alzheimer dementia who was admitted to an aged mental health inpatient unit with a relapse of his schizoaffective disorder. He was admitted from a nursing home where he had resided for 4 years, during which time his illness had been stable except for an admission some 12 months earlier. On admission, after minor changes to his pharmacological management, supportive psychotherapy and allied health input, his condition returned to baseline. When the medical team liaised with his nursing home to arrange his return, they were informed that he could not return because they did not have the facilities required for him. When the patient was informed of this, there was subsequent deterioration in his mental state. After his brother with enduring power of attorney threatened legal action, he was accepted back at the home. The community mental health team who are continuing his care in the community have indicated that he remains stable following discharge. There is a high proportion of nursing home residents with a mental illness other than dementia.2 United States and Canadian data suggest that older adults with mental illness experience stigma from nursing homes (mostly due to fear of aggression and other behaviour) and poor quality care.3 Such patients tend to be placed in the first instance in nursing homes with deficiencies in care and with a paucity of resources and specialised expertise to provide care for this group;4 this probably explains the recourse to the “no returns” policy experienced by our patient. Such situations cause harm to the patient and contribute to bed block in hospitals.5 The issues involving this particularly vulnerable population will hopefully be uncovered in the Royal Commission into Aged Care Quality and Safety. We encourage improved mental health literacy in Australian nursing homes.

Malcolm P Forbes · Angelo Ferraro

In reply

Carmelle Peisah · Tiffany Jessop · Henry Brodaty

To the Editor: We note with interest the research letter by Taft and colleagues regarding unplanned pregnancy in Australia.1 An audit of terminations of pregnancy in our Australian metropolitan hospital service (Austin Health, Melbourne) supports the findings of the national survey while highlighting additional areas of educational need. Of 309 women (aged 15–46 years) who underwent terminations for unwanted pregnancy from January 2016 to October 2018, 145 chose surgical termination and 164 women chose medical termination. Compared with the national survey, our cohort had similar rates of not using contraception (48.2% v 56.5%) and contraception failure (51.8% v 41.4%).1 Failed barrier and oral contraception respectively accounted for 52.1% and 29.3% of contraception failures. This differs from the survey findings, where the most common contraception failure was oral contraception, followed by condoms.1 There is a paucity of Australian literature reporting long‐acting reversible contraception (LARC) usage following termination; however, a Swedish study found a rate of 34%2 and a New Zealand public hospital service reported a rate of 44.5%.3 Our post‐termination LARC rate was 58.2% (72.5% following surgical termination and 43.2% following medical termination). We attribute the higher rate to our conscientious use of tiered counselling4 (ie, presenting the most efficacious method first) to enable women to make informed decisions regarding contraception. The most common choice of contraception following surgical termination was a levonorgestrel‐releasing intrauterine device (Mirena [Bayer]) (56.0%); however, oral contraception was more popular (38.8%) following medical termination, followed by Mirena (25.9%). A British study also found that women more often chose an intrauterine device or implant after surgical termination,5 suggesting that ease of insertion under anaesthetic influences choice. Of the 134 women documented as not using contraception in our audit, three had received inaccurate medical advice regarding contraception, or had been inappropriately labelled as infertile due to age, endometriosis or polycystic ovary syndrome. A further three pregnancies occurred as a result of removing LARC without arranging alternative contraception. We support the researchers’ conclusion regarding the need to explore reasons for poor contraception uptake and determine where education would be most helpful.1 In addition to increasing access to and promoting informed choice of LARC in primary health care settings,6 greater efforts to improve practitioner knowledge of contraception management, as well as common gynaecological conditions to aid appropriate diagnosis and evaluation of fertility impact, are vitally important.

Sophie L Yeates · Charlotte V Elder · Sonia R Grover