Volume 211 Issue 10

Over two decades of Dutch experience can inform deliberations about the nature of a regulatory framework in Australian jurisdictions

Bregje Onwuteaka‐Philipsen · Lindy Willmott · Ben P White

Australian Genomics is calling for a change in research ethics and governance frameworks

on behalf of Australian Genomics

Medical and public health research is dependent on the valid analysis and interpretation of data, which requires investment in biostatistics as a fundamental scientific discipline for health research

Katherine J Lee · Margarita Moreno‐Betancur · Jessica Kasza · Ian C Marschner · Adrian G Barnett · John B Carlin

Despite harm reduction being a pillar of the Australian National Drug Strategy, current governments are shying away from pill-testing as a viable strategy

Jody Morgan · Alison Jones

The current Ebola outbreak is a public health emergency of international concern, and while international risk remains low, we need to remain vigilant for symptomatic travellers

Luke J Vos

An 88-year-old woman presented with 2 months of right upper quadrant pain, weight loss, and 3 days of fevers

Sudharsan Venkatesan · Henrik Falhammar

Routine admission screening of patients is desirable, but financial and personnel support for diabetes services is essential

Matthew JL Hare · Jonathan E Shaw

Glucose and HbA1c screening alone does not increase detection of previously unidentified diabetes in patients admitted from EDs

N Wah Cheung · Lesley V Campbell · Gregory R Fulcher · Patrick McElduff · Barbara Depczynski · Shamasunder Acharya · John Carter · Bernard Champion · Roger Chen · David Chipps · Jeff Flack · Jen Kinsella · Margaret Layton · Mark McLean · Robert G Moses · Kris Park · Ann M Poynten · Carol Pollock · Debbie Scadden · Katherine T Tonks · Mary Webber · Chris White · Vincent Wong · Sandy Middleton

More systematic data collection could assist clinicians and patients when considering overseas travel for organ transplantation

Georgia Smith · Diba Gujari · Oscar Russell · Lyle Palmer · Maeghan Toews · Germaine Wong · Wai Lim · Stephen McDonald · Phillip Clayton · Dominique Martin · Patrick T Coates

FC testing of patients with lower gastrointestinal symptoms could reduce the number with functional disorders undergoing colonoscopy

Yoon‐Kyo An · David Prince · Fergus Gardiner · Teresa Neeman · Ecushla C Linedale · Jane M Andrews · Susan Connor · Jakob Begun

The evidence suggests that calcium and vitamin D supplements should not be provided routinely to healthy older individuals

Ian R Reid · Mark J Bolland

To the Editor: The editorial by Murnion and Conigrave1 and the article by Crossin and colleagues2 on the dangers of misuse of pregabalin are a timely warning to all prescribers. The black market utility (based on testimonies) and frequent misuse of pregabalin is well known both academically and to prescribers in prison environments.3,4 Harm relating to gabapentinoid use is noted to be increasing globally. A 2017 case–control study showed a dramatic increase in relative risk of death with opioid and gabapentinoid versus opioid alone.5 People leaving prison are at a higher risk of opioid overdose death, partly because of loss of tolerance.6,7 This will likely be compounded by inappropriate gabapentinoid prescribing. In New South Wales prisons, the Justice Health and Forensic Mental Health Network sees many patients who present seeking pregabalin and other prescription drugs in our health clinics. Patients often enter custody using high doses of medications prescribed in the community, including gabapentinoids, benzodiazepines and opiates. The Network applies a multidisciplinary team approach between primary care, pharmacy, and drug, alcohol and mental health services for these complex patients. Furthermore, clinicians undertake regular medication reviews of patients; medications that are not indicated are deprescribed to reduce potential harm to patients.8,9 The Network has developed management guidelines around gabapentinoid use, including regular review of prescriptions by general practitioners and the clinical director. Off‐label use is discouraged. Pregabalin is always a supervised medication, and dose limits and deprescribing programs are in place to limit availability if not indicated. Alternate medications for the management of diagnosed neuropathic pain are effective and may pose less risk in prison environments.8,9 Gabapentinoid drugs are not used as an alternative to opiate pain medications in NSW prisons. Patients are assessed and given appropriate medications according to the quality and safe use of medicines approach, and medication charts are regularly audited to ensure safe prescription of medications. There has been an overall reduction in actual gabapentinoid prescribing in NSW prisons in recent years. We encourage all Australian prescribers to ensure care around prescribing of gabapentinoid and other medications, especially for complex patients with drug and alcohol misuse and polypharmacy issues.

Gary Nicholls · Peter Samios · Stephen Hampton

To the Editor: We read with interest the recent publication by Rowe and colleagues.1 The authors reported low influenza vaccine coverage (39%) among pregnant women in Victoria from 2015 to 2017. Individual‐level factors associated with this finding included greater maternal age, primigravidity, early antenatal care and GP‐led antenatal care.1 As the authors accurately concluded, integrating vaccine delivery into antenatal care pathways is important to improve pregnant women's vaccination coverage.1 Our team reported on this previously, with coverage approximating 90% achieved by introducing standing orders for midwives.2 In collaboration with key stakeholders from six Victorian maternity services, a Monash University‐led project funded by Better Care Victoria is currently underway to implement integrated vaccination strategies and measure the cost and magnitude of improvement in maternal immunisation coverage in Victoria,3 the results of which will be available by the end of 2019. One of the key findings in the article by Rowe and colleagues1 is higher odds of influenza vaccination in women who gave birth after 37 weeks' gestation compared with women who gave birth before 28 weeks (adjusted odds ratio [aOR], 4.74; 95% CI, 3.54–6.35). A similar finding was reported for women who gave birth between 28 and 36 weeks gestation (aOR, 4.13; 95% CI, 3.07–5.56).1 This finding has two important implications. Firstly, it may indicate a potential beneficial effect of influenza vaccine received by pregnant women in reducing pre‐term birth (< 37 weeks' gestation). This is consistent with a recent systematic review and meta‐analysis that reported inactivated influenza vaccine to have a protective effect against pre‐term birth and low birth weight.4 Secondly, this finding may serve as an opportunity to emphasise the safety and benefits of influenza vaccines on perinatal outcomes. As the authors alluded to in their discussion, pregnant women tend to view influenza as primarily a health risk for themselves rather than for their infants.1 Given the importance of health care providers' recommendations in encouraging influenza vaccination among pregnant women, timely dissemination of the potential benefit in lowering the chance of pre‐term birth could further empower health care providers to recommend influenza vaccines to pregnant women.5

Khai Lin Kong · Michelle L Giles · Euan M Wallace

In reply

Stacey Rowe · Karin Leder · Allen C Cheng

To the Editor: Last month, the Medical Journal of Australia called for manuscript submissions on the topic of “Women in medicine and medical leadership in Australia — is there gender equity?” We answer with a resounding no. Indeed, we believe the question itself perpetuates gender disparity by suggesting that the answer is up for debate. There is overwhelming evidence to demonstrate that gender equity in medicine and medical leadership in Australia has not been achieved. Women have had gender parity in Australian medical schools for decades; however, they represent only 28% of medical deans and 12.5% of hospital chief executive officers.1 In February 2019, The Lancet dedicated an entire issue on advancing women in science, medicine and global health.2 The MJA has also reported on capacity, capability and credibility barriers for women in health leadership.3 These disparities are even greater for Aboriginal and Torres Strait Islander women, women of colour and women with disabilities. There is an urgent need to shift our focus from asking whether gender inequity exists to implementing and evaluating sustainable strategies to change the status quo. This year, the Australian Medical Association of Victoria changed its constitution to include a 40% gender quota for its board.4 The Royal Australasian College of Surgeons has established a business plan with tangible indicators to promote leadership and flexible training for its female surgeons.5 Both the Women in Tropical Health Catalyse Program6 in Australia and Wāhine Connect (www.wahineconnect.nz) in New Zealand offer mentoring for women in medicine and medical leadership. We need to bolster current strategies aimed at improving the number of women in medical leadership. Moreover, we need to keep our workplaces, colleges, committees, professional associations and academic journals accountable for the role they play in the persistent gender inequities in medicine and medical leadership in Australia. We invite the MJA to follow The Lancet's example and dedicate an entire issue to strategies that advance women in medicine and medical leadership. We implore it not to ask “is there gender equity?” when the answer to this question is patently clear. The answer is no.

Allison Hempenstall · Jillian Tomlinson · Marie M Bismark

To the Editor: I thank Whitfield and colleagues for their article about hyperemesis gravidarum and abnormal liver function in pregnancy.1 In a 15‐month prospective study in South West Wales, abnormalities of liver function were present in 3% of pregnancies.2 In managing pregnant women with hepatic dysfunction, it is important to consider uncommon causes of liver disease that may be associated with serious maternal and fetal morbidity and mortality if untreated. Addison disease is a rare but potentially life‐threatening condition that may imitate hyperemesis gravidarum in presenting with vomiting, weight loss, postural hypotension and hyponatraemia.3,4 Addison disease has also been associated with elevated hepatic transaminases in 16 published cases, reversing with glucocorticoid replacement.5 In excluding Addison disease, the physiological rise in cortisol during pregnancy must be considered using trimester‐specific reference ranges for short synacthen testing.6 In the pregnant woman with unexplained liver disease and fever, acyclovir should be administered empirically, given the absence of cutaneous vesicles in up to 80% of affected patients and the extreme maternal and fetal mortality associated with untreated herpes simplex virus hepatitis.7 Budd–Chiari syndrome should be considered with abnormal liver function in pregnancy with abdominal pain, hepatomegaly and ascites. Additionally, the use of herbal and over‐the‐counter medications should be sought in pregnant women with abnormal liver function, given the high rates of complementary and alternative medicine use in pregnancy and their potential to cause liver injury.8 Investigations need to be interpreted with regard to gestational physiological changes, as copper, ceruloplasmin, α‐1 antitrypsin and alkaline phosphatase levels rise significantly in pregnancy. Serum lipase levels are commonly elevated in hyperemesis gravidarum — levels up to ten times normal have been reported in the absence of pancreatitis.9 Antithrombin III levels may be useful to distinguish acute fatty liver of pregnancy from pre‐eclampsia with haemolysis, elevated liver enzymes and low platelets.10 Bile acid levels are not specific for intrahepatic cholestasis of pregnancy, being elevated in many hepatic disorders including non‐alcoholic fatty liver disease. Twenty per cent of women with pruritus typical of intrahepatic cholestasis of pregnancy have normal bile acids and liver function at presentation, and symptoms may precede abnormal biochemistry by up to 6 weeks.11 In addition to ondansetron and glucocorticoids, mirtazapine has been effective in the management of hyperemesis gravidarum in case reports.12

Adam Morton

Associate Professor Allison Joy Milner, who died in a tragic accident at Princes Park, Carlton on 12 August 2019, was brilliant, funny, trusting, and a loving mother

Anne Kavanagh · Tania King · Tony LaMontagne