Issues
Volume 217 Issue 8
News
News briefs
Deep brain stimulation effective for severe OCD Deep brain stimulation can halve the symptoms of severe obsessive–compulsive disorder (OCD), according to a pooled data analysis of the available evidence, published in the Journal of Neurology, Neurosurgery and Psychiatry. The analysis found that two‐thirds of those affected experienced substantial improvement within two years. OCD is characterised by intrusive and persistent obsessive thoughts along with dysfunctional and ritualised behaviours. It is thought to affect up to 3% of people. Drugs and cognitive behaviour therapy can be very effective, but in approximately 1 in 10 cases, such approaches do not work. The researchers systematically reviewed and pooled the results of 34 clinical trials published between 2005 and 2021, to critically assess how well deep brain stimulation alleviates OCD and associated depressive symptoms in adults. The 34 studies included 352 adults with an average age of 40 years, and severe to extreme OCD, the symptoms of which had not improved despite treatment. In 23 of the studies, participants were required to have had persistent symptoms for five or more years before consideration for surgery. Of the remaining 11 studies, one had a requirement of more than a decade of symptoms and two or more years of failed treatment; another required at least one year of failed treatment; and five did not specify any requirements. On average, symptoms had persisted for 24 years. Coexisting mental health issues were reported in 23 studies and included major depression (over half of participants), anxiety disorder, and personality disorder. The average monitoring period after deep brain stimulation was two years. The final pooled data analysis, which included 31 studies involving 345 participants, showed that deep brain stimulation reduced symptoms by 47%, and two‐thirds of participants experienced substantial improvement within the monitoring period. Secondary analysis revealed a reduction in reported depressive symptoms, with complete resolution in nearly half of participants and partial response in a further 16%. Twenty‐four studies reported complete data on serious side effects, including hardware‐related complications, infections, seizures, suicide attempts, stroke, and the development of new obsessions associated with stimulation. Overall, 78 participants experienced at least one serious side effect. https://jnnp.bmj.com/content/early/2022/07/31/jnnp‐2021‐328738 Exposure to air pollution may worsen autism‐related hospital admissions in children Children with autism may be at heightened risk of being admitted to hospital if they are exposed to air pollution for relatively brief periods, with boys more at risk than girls, suggests research published in BMJ Open. Admissions for issues such as hyperactivity, aggression or self‐injury might be prevented by minimising such children’s exposure to air pollution. It is believed that short term exposure to air pollution (days to weeks) can induce systemic inflammation and neuroinflammation, potentially increasing the risk of hospital admission in people with autism. Previous air pollution studies have focused on the association between long term exposure to air pollution (months to years) during pregnancy and early postnatal period, and autism spectrum disorder (ASD) development among children. The researchers drew on official Korean government data on daily hospital admissions for autism among children aged 5–14years between 2011 and 2015. They collected data on national daily levels of fine particulate matter (PM2.5), nitrogen dioxide (NO2) and ozone (O3) in each of the 16 regions in the Republic of Korea for up to six days. The average daily number of hospital admissions for autism during the study period was 8.5 for children with autism and was much higher for boys (seven) than for girls (1.6). A 10μg/m3 increase in PM2.5 levels was associated with a 17% higher risk of hospital admission for autism, and a 10 parts per billion increase in NO2 and O3 was associated with a 9% and 3% higher risk, respectively. The researchers calculated that exposure to these pollutants was associated with a one‐quartile increase (8.2μg/m3 for PM2.5; 6.7 parts per billion for NO2, and 11.3 parts per billion for O3), which corresponds to a 29% higher risk of hospital admission for autism, with NO2 exerting the strongest effects. The researchers acknowledge that they used regional air pollution levels rather than individual ones, which could have affected their findings, and that children with autism with mild symptoms might be less likely to receive psychiatric treatment and so might not have been included. https://bmjopen.bmj.com/content/12/9/e058286
Perspectives
Twenty‐one years at the Uniting Medically Supervised Injecting Centre, Sydney Australia: addressing the remaining questions
The key themes from the 21 years of MSIC experience are that good policy, with clear legislation and careful management of clients within a harm reduction framework, can and does alleviate problems that may be perceived as inherent to the operation of such services
Carolyn A Day · Allison Salmon · Marianne Jauncey · Mark Bartlett · Amanda Roxburgh
Latest evidence casts further doubt on the effectiveness of headspace
Despite significant government expenditure on headspace, youth mental health outcomes still need improvement
Steve Kisely · Jeffrey CL Looi
Robotic surgery: getting the evidence right
Obtaining high quality evidence relating to adoption of robotic surgery presents challenges
Wei Shen Tan · Anthony Ta · John D Kelly
Medical education
Mycobacterium haemophilum in a patient with inflammatory bowel disease
A 38-year-old woman with longstanding Crohn’s disease presented with 7 months of a nonhealing widespread rash
Fleur W Kong · David Wong · Kendall Sharpe · Louis Pool · James Muir
Osteopoikilosis: benign bone islands in periarticular bones
A 41-year-old man presented with right knee pain for 3 months
Te‐Feng A Chou · Ching‐Hua Hsiao
Editorials
Breast cancer metastasis: mapping long term outcomes in Australia
Characterising the ongoing but changing risk of relapse after breast cancer diagnosis improves surveillance planning and patient care
Andrew Redfern · Hilary Martin
Feticide and late termination of pregnancy: an essential component of reproductive health care
Decisions about late abortion and care for women and their families are supported by sensitive and professional care
Caroline M Costa
Research
Long term risk of distant metastasis in women with non‐metastatic breast cancer and survival after metastasis detection: a population‐based linked health records study
DM risk declines with time from diagnosis, and the risk of breast cancer death declines with time from initial DM detection
Sarah (Sally) J Lord · Benjamin Daniels · Belinda E Kiely · Dianne L O'Connell · Jane Beith · Sallie Pearson · Kim‐Lin Chiew · Max K Bulsara · Nehmat Houssami
Late termination of pregnancy at a major Queensland tertiary hospital, 2010–2020
Safe late termination services are essential for equitable reproductive health care for women
Shannyn Rosser · Renuka Sekar · Johanna Laporte · Gregory J Duncombe · Alexa Bendall · Christoph Lehner · Carol Portmann · Pauline McGrath · Karin Lust · Peter Ganter · Sailesh Kumar
Guideline summary
COPD‐X Australian guidelines for the diagnosis and management of chronic obstructive pulmonary disease: 2022 update
The COPD-X guidelines aspire to standardise COPD care, optimise health outcomes, and enhance the quality of life of people with COPD
Eli Dabscheck · Johnson George · Kelcie Hermann · Christine F McDonald · Vanessa M McDonald · Renae McNamara · Mearon O’Brien · Brian Smith · Nicholas A Zwar · Ian A Yang
Narrative review
Modern paradigms for prostate cancer detection and management
Over the past decade, detection and management of prostate cancer have evolved, with the focus now placed on harm minimisation, reducing overdiagnosis and avoiding overtreatment
Isabella SC Williams · Aoife McVey · Sachin Perera · Jonathan S O’Brien · Louise Kostos · Kenneth Chen · Shankar Siva · Arun A Azad · Declan G Murphy · Veeru Kasivisvanathan · Nathan Lawrentschuk · Mark Frydenberg
Letter
Priced out of training?
To the Editor: Data from the United States, the United Kingdom, and Canada have highlighted rapidly rising medical education and specialty training costs as a key deterrent to diverse and lower socio‐economic medical graduates from pursuing specialty training. Australia is likely to be experiencing similar patterns, but there have been little published data or research in the domain. For example, a study into costs of specialty surgical training in the United Kingdom and Ireland revealed that medical officers can spend up to £71000 on mandatory training costs during their Fellowship,1 on an average junior medical officer salary of £41000 pounds per year.2 This does not include the additional expected costs such as conferences and postgraduate degrees. In the background, mean debt on graduation from medical school has increased by 55%, from £17892 in 2004 to £27655 in 2014.3 A 2015 study predicted that most English medical students will be unable to repay their student loan before reaching the 30‐year write‐off.4 Australia is experiencing similar forces. When university fees were deregulated in 2014, the then Australian Medical Association president Brian Owler5 and the Grattan Institute6 predicted that full‐fee domestic places in Australian medical schools could rise by up to 270% to $70000 per annum. As foretold, a full‐fee domestic student now pays up to $77888 per year tuition, for a total estimated course fee of $335707 (Doctor of Medicine, University of Melbourne, 2022),7 which exceeds the combined HELP (Higher Education Loan Program) loan limit of $156847.8 Unlike overseas, there are no reports on medical specialty training cost trends in Australia. However, archived publicly available data give a general sense that local costs are rising much like those overseas. For example, annual training fee sums range from $483 (Royal Australian College of General Practitioners9) to $5714 (Australasian College of Dermatologists10) between colleges. This fee covers mandatory trainee subscription or membership to the college but does not include all the other mandatory costs such as exam and elevation fees, which vary between training programs. There is undoubtedly considerable difference in fee structures, and such numbers are difficult to compare between colleges. Nevertheless, without transparent data, we are unable to interrogate the concerns that have been identified in overseas studies. The ramifications are potentially vast and varied. New Zealand data show that student loan debt is a common influence on choice of specialty and is a consideration when choosing to stay in the country to practise once trained.11 This may lead to long term consequences for the structure of the medical workforce and appropriate service delivery for patients. As a first step, it is critical that we take action to improve collection and transparency of medical training cost data in Australia.
James Brown
The 2022 report of the MJA–Lancet Countdown on health and climate change: Australia unprepared and paying the price
Paul J Beggs · Ying Zhang · Alice McGushin · Stefan Trueck · Martina K Linnenluecke · Hilary Bambrick · Anthony G Capon · Sotiris Vardoulakis · Donna Green · Arunima Malik · Ollie Jay · Maddie Heenan · Ivan C Hanigan · Sharon Friel · Mark Stevenson · Fay H Johnston · Celia McMichael · Fiona Charlson · Alistair J Woodward · Marina B Romanello
A vision of a One Health system for Australia: on the need to rethink our health system
Sandra G Steele · Jenny‐Ann LML Toribio · Siobhan M Mor
Climate change can be seen through a disaster medicine lens
George Braitberg
Quality improvement strategies in trauma care: review and proposal of 31 novel quality indicators
for the Trauma Care Verification and Quality Improvement Writing Group †
Seafarers on the shore: issues raised by Australian doctors treating seafarers
John J Bockxmeer · Nilukshi Ranwala
Australia needs to implement a national health strategy for doctors
Chanaka Wijeratne · Margaret P Kay · Mark H Arnold · Jeffrey CL Looi