Issues
Volume 212 Issue 5
News
News briefs
Assisted dying not driven by poverty or poor access to health care A Canadian study of people who received known as medical assistance in dying in Ontario found that about three‐quarters were in the care of palliative care practitioners at the time of their request for voluntary assisted dying, and that those assisted were younger, of higher socio‐economic status, and more likely to be married than the general population. These findings ease concerns that requests for assisted dying are driven by lack of access to palliative care services or by socio‐economic vulnerability. The study was published in CMAJ with a related editorial. Voluntary assisted dying has been legal in Canada since June 2016, and by October 2018, 6749 Canadians had received medical assistance in dying. The Canadian and Quebec governments have been discussing new eligibility criteria for medical assistance in dying after the Quebec Superior Court ruled that one provision of the law violated the Canadian Charter of Rights and Freedoms. The investigators compared clinical and socio‐economic data from the Office of the Chief Coroner for Ontario and ICES (a health informatics not‐for‐profit corporation) for 2241 Ontarians who had received medical assistance in dying with data for the 186 814 people in the province who had died during June 2016 – October 2018. The median age of patients who had received assistance to die was 75 years and half were women; almost two‐thirds of patients (64%) had cancer, 12% of patients had neurodegenerative diseases, 8.5% cardiovascular diseases, and 7.5% respiratory diseases. Patients who received assistance to die reported both physical (99.5%) and psychological (96.4%) suffering. The study found that only 6.6% of families reported problems obtaining medical assistance for dying, and these problems were not associated with socio‐economic status. The authors noted, however, that the dataset included only people who had actually received assistance, so their findings would not reflect the experience of patients who had requested but not received medical assistance in dying. https://www.cmaj.ca/content/early/2020/02/11/cmaj.200016 https://www.cmaj.ca/content/early/2020/02/11/cmaj.200213 Cracking the code for hookworm infestation Monash University researchers have uncovered a mechanism that allows hookworms to evade the human immune system, providing new hope in the search for a vaccine. Importantly, the researchers, led by Professor Nicola Harris of the Monash University Central Clinical School, may have discovered why infected people are unable to kill these parasites. Hookworms infect nearly around 700 million people around the world, mostly in countries where sanitation is poor and people often walk barefoot. The immune system is critical to thwarting infection by the hookworm, but the parasites are often able to evading its defences and people typically remain infected for life, often resulting in death or complications related to anaemia. The research, published in Cell Host and Microbe, shows that neutrophils, white blood cells central to immune responses, can kill hookworms by releasing neutrophil extracellular traps (NETs) of toxin‐coated DNA. However, hookworms have evolved a mechanism for degrading the DNA backbone of the trap, allowing it to continue infecting its host. Professor Harris and her colleagues believe that NETs could be effective in people in hookworm‐prone areas by boosting their immunity. Professor Harris says that the discovery could lead to a vaccine to achieve this goal. “We may now be able to look at new vaccination approaches that target the enzyme secreted by the hookworm parasite to alleviate infestation and to decrease the likelihood of re‐infection.” https://doi.org/10.1016/j.chom.2020.01.011
Perspectives
More than a refresh required for closing the gap of Indigenous health inequality
If we are committed to closing the gap, we should be committed to transforming relationships of power between Indigenous and non-Indigenous people
Chelsea J Bond · David Singh
Lessons learned in genetic research with Indigenous Australian participants
Genetic research with Indigenous Australians is achievable with community engagement and appropriate governance mechanisms in place
Steven YC Tong · Heather D'Antoine · Melita McKinnon · Kyle Turner · Maui Hudson · Ngiare Brown · Jonathan R Carapetis · Dawn C Bessarab
Investing in the health of Aboriginal and Torres Strait Islander adolescents: a foundation for achieving health equity
Without specific investments in the health of adolescents, Australia will not redress health inequalities experienced by Aboriginal and Torres Strait Island peoples
Peter Azzopardi · Ngaree Blow · Tara Purcell · Ngiare Brown · Tirritpa Ritchie · Alex Brown
Setting the record straight: sexually transmissible infections and sexual abuse in Aboriginal and Torres Strait Islander communities
The automatic assumption that sexually transmissible infections in young people means sexual abuse further stigmatises them and discourages them from presenting to health services
James S Ward · Belinda Hengel · Donna Ah Chee · Olga Havnen · John D Boffa
Ethics and law
Self‐binding directives for mental health treatment: when advance consent is not effective consent
Variation in Australian law concerning self-binding directives for mental illness is unnecessarily complex for clinicians
Katrine Del Villar · Christopher J Ryan
Editorials
Time to develop guidelines for screening and management of atrial fibrillation in Indigenous Australians
Screening guidelines specific to the needs of Australia’s Indigenous population are needed
Nicole Lowres · Ben Freedman
Ending cheap alcohol gets promising results
The evidence from real world implementation is compelling
Mike Daube · Julia Stafford
Research
Differences in stroke risk and cardiovascular mortality for Aboriginal and other Australian patients with atrial fibrillation
Objectives: To assess the risks of stroke and cardiovascular mortality for Aboriginal and non‐Aboriginal Australians with atrial fibrillation. Design: Retrospective data linkage cohort study. Setting, participants: All people aged 20–84 years hospitalised with atrial fibrillation in Western Australia during 2000–2012. Main outcome measures: Stroke incidence rates and mortality after hospitalisation for atrial fibrillation, and 10‐year risks of stroke and of cardiovascular and all‐cause mortality. Results: Among 55 482 index admissions with atrial fibrillation, 7.7% of 20–59‐year‐old patients and 1.3% of 60–84‐year‐old patients were Aboriginal Australians. A larger proportion of Aboriginal patients aged 20–59 years had CHA2DS2‐VASc scores of 2 or more (59.8% v 21.8%). In 20–59‐year‐old Aboriginal patients, the incidence during follow‐up (maximum, 10 years; median, 7.1 years) of stroke (incidence rate ratio [IRR], 3.2; 95% CI, 2.5–4.1) and fatal stroke (IRR, 5.7; 95% CI, 3.9–8.9) were markedly higher than for non‐Aboriginal patients. Stroke incidence was higher for 60–84‐year‐old patients, but the difference between Aboriginal and non‐Aboriginal patients was smaller (IRR, 1.6; 95% CI, 1.3–2.0). Cardiovascular mortality during follow‐up was also higher for 20–59‐year‐old Aboriginal patients (IRR, 4.4; 95% CI, 4.3–5.9). The hazards of stroke (adjusted HR [aHR], 1.67; 95% CI, 1.22–2.28) and cardiovascular mortality (aHR, 1.47; 95% CI, 1.18–1.83) in younger Aboriginal patients remained significantly higher after multivariable adjustment; age/sex, principal diagnosis of atrial fibrillation, and CHA2DS2‐VASc score were the most influential factors. Conclusion: Stroke risk and cardiovascular mortality are markedly higher for Aboriginal than non‐Aboriginal patients with atrial fibrillation, particularly for patients under 60. Strategies for providing evidence‐based therapies and cardiovascular prevention to Aboriginal people with atrial fibrillation must be improved.
Lee Nedkoff · Erin A Kelty · Joseph Hung · Sandra C Thompson · Judith M Katzenellenbogen
Systematic review
Non‐clinical eye care support for Aboriginal and Torres Strait Islander Australians: a systematic review
Greater investment is needed to support eye health coordinators, community-based liaison officers, and family members and carers
Aryati Yashadhana · Ling Lee · Jessica Massie · Anthea Burnett
Research letters
The impact of an alcohol floor price on critical care admissions in Central Australia
Introducing the floor price was followed by a significant reduction in ICU admissions associated with acute alcohol misuse
Paul J Secombe · Penny Stewart · Alex Brown · Michael J Bailey · David Pilcher
Validating Indigenous status in a regional Queensland hospital emergency department dataset with patient‐linked data
Inaccurate recording of Indigenous status in administrative datasets can influence health service decision making
Mary O'Loughlin · Linton Harriss · Jane Mills · Fintan Thompson · Robyn McDermott
Narrative review
Skin infections in Australian Aboriginal children: a narrative review
Addressing the social determinants of health is ultimately needed for skin infections in Aboriginal and Torres Strait Islander children to have disease rates similar to their non-Aboriginal peers
Lucy Davidson · Jessica Knight · Asha C Bowen
Letters
The increasing use of shave biopsy for diagnosing invasive melanoma in Australia
To the Editor: De Menezes and colleagues1 report increasing use of shave biopsy for melanoma diagnosis in association with significant rates of base transection. They cite a wide range of base transection rates in the literature (7–68%), giving pause for thought: what is at play here besides the shave biopsy itself? This is an important question, as the incidence of invasive melanoma rose significantly over the study period along with a doubling of the frequency of shave biopsy. Particularly in Queensland, dubiously honoured with the title of “melanoma capital of the world,” we must be cautious about dismissing this efficient and low cost procedure. De Menezes and colleagues1 could not assess clinician intent regarding biopsy depth, and we do not know whether melanoma was the provisional diagnosis. There is an important distinction between superficial shave biopsies and saucerisation, which is acknowledged but not examined. Saucerisation would be expected to produce lower rates of base transection and tumour upstaging. The authors have not stratified the base transection rate by year. It would be useful to know whether better education, increasing use of dermoscopy and improved shave tools have influenced base transection over the 10‐year period. What is the standard of care for evaluating potential melanomas? Should more excisional biopsies be performed to increase microstaging accuracy when base transection has not been proven to reduce survival? We agree that excisional biopsy is the best way to evaluate a highly suspicious lesion. However, the role of the shave biopsy must be defended, particularly in patients with many lesions, in older and relatively immobile patients, and in rural populations. De Menezes and colleagues1 acknowledge the benefits of shave biopsy in terms of cost and reduced risk of missed or delayed diagnosis when the index of suspicion is low. Better training and improved shave equipment are the keys to ensuring better results.
Lachlan A Byth · Jenny Byth
The increasing use of shave biopsy for diagnosing invasive melanoma in Australia
In reply
Sara L Menezes · John W Kelly · Victoria Mar
Careers
Stay engaged, keep saying yes
Dr Annette Holian is a veteran orthopaedic surgeon with a career spanning paediatrics, trauma medicine, military service and international rescues …
Cate Swannell
Citation metrics for appraising scientists: misuse, gaming and proper use
John PA Ioannidis · Kevin W Boyack
A global public health emergency and the MJA rapid review process
Nicholas J Talley
Breathing life into Australian diabetes clinical guidelines
Heath White · Britta Tendal · Julian Elliott · Tari Turner · Sofianos Andrikopoulos · Sophia Zoungas
Misgendering and experiences of stigma in health care settings for transgender people
Irene J Dolan · Penelope Strauss · Sam Winter · Ashleigh Lin
Tafenoquine for the radical cure and prevention of malaria: the importance of testing for G6PD deficiency
Robert J Commons · James S McCarthy · Ric N Price
Hidden in plain sight: umbilical melanoma
Tom Kovitwanichkanont · Shoba Joseph · Leona Yip