Volume 224 Issue 1

There is consistent evidence of who is more likely to practise in a rural location; however, current selection criteria used by most specialty colleges do not reflect this. In fact, our evidence-based perspective article shows how specialty selection is likely driving many rural interested graduates away from rural pathways, perhaps never to return post-fellowship. The Australian Government has strongly invested in rural training, with greatly increased opportunities for end-to-end pathways and raised awareness of social accountability of training programs. However, specialty training pathways have been slow to change the selection criteria, which should align with supporting workforce diversity and distribution into rural areas. We highlight potentially untapped opportunities to directly address workforce distribution that require negligible financial costs to change criteria and processes.

Matthew R. McGrail, Jenny May AM, Katherine Logan

The burden of disease estimates from the Australian Institute of Health and Welfare are influential in driving priorities for actions across research, policy and practice. Following the latest estimates in 2024, much attention focused on top risk factors including obesity, tobacco and diet. Meanwhile, upstream social, economic and political drivers were overlooked. In this perspective, we argue that to effectively move the dial on disease burden, we must shift our focus from downstream action on individual-level risk factors to upstream action on structural causes. Failure to do so represents a missed opportunity to improve population health and tackle health inequity.

Saman Khalatbari-Soltani, Edward Jegasothy, Seye Abimbola, Anita van Zwieten

Healthcare in Australian custodial settings is hampered by fragmented care, a lack of consistent standards and a lack of accountability. Creating national minimum standards for healthcare in custodial settings, with the aim of equivalence to community standards, will be an important step in reducing health inequalities for some of Australia's most marginalised people.

Thileepan Naren, Damien Linnane, Dallas Widdicombe, Jocelyn Chan, Stuart Kinner

Over recent decades, the medical profession has undergone significant changes due to the influence of managerialism, which is characterised by standardisation, efficiency and cost control. Although these principles aim to improve sustainability and transparency within healthcare systems, they often conflict with fundamental aspects of medical professionalism and patient-centred care. This perspective explores how managerialism may negatively affect the medical profession, focussing on its impact on clinician autonomy, the changing nature of medical work, professional identity and collegial relationships within hospital settings. Key challenges faced by doctors include diminishing control over patient care, growing administrative burden, increasing burn-out, erosion of professional values and identity, and fragmentation of collegiality. To address these issues, this perspective advocates for institutional change such as hybrid governance models that integrate professional and managerial expertise to ensure managerial goals remain aligned with clinical realities. Professional bodies and institutions should empower doctors with managerial and leadership competencies to influence organisational change, reconcile clinical and managerial priorities, and uphold professional values and quality patient care within the evolving healthcare landscape. Effective reform requires the considerate integration of managerial systems into healthcare to strengthen, rather than undermine, the professional foundations and ethical values that give medicine its integrity and meaning.

Evelyn He, Behnam Shaygi, Anousha Yazdabadi, Christen D. Barras, Paul M. Parizel, Hamed Asadi

Natalie Taylor, Zhicheng Li, Cathelijne van Kemenade, Jackie Curtis, Patrick Bolton

Restrictions on social media access for users under 16years raise a critical question about how adolescents in Australia will access sexual and reproductive health (SRH) information, especially where traditional systems often fall short. Social media has become an important source of SRH education, offering timely and relatable content that bridges gaps left by formal education and healthcare. As access to these platforms is restricted, other pathways must be strengthened. This includes investing in comprehensive in- and out-of-school sexuality education, youth-friendly primary care services and safe digital platforms designed with and for adolescents.

Olena Ivanova, Anisa R. Assifi, Danielle Mazza

An older man with Crohn's disease underwent emergency laparotomy for small bowel perforation. A peri-incisional vesiculobullous eruption developed 5days later. Histopathology demonstrated viral cytopathic changes, immunohistochemistry was positive for herpes simplex virus and HSV-1 DNA confirmed by polymerase chain reaction test, representing the first reported case of localised herpes simplex following abdominal surgery.

Jessica S. Bulluss, Paul Chee, Matthew J. Verheyden

A man aged in his 40s, recently returned from Uganda, was hospitalised with Plasmodium falciparum malaria, with hyperparasitaemia of ~1.5×106 parasites/μL (26%). He received intravenous artesunate followed by artemether–lumefantrine. However, parasite clearance was delayed, and despite a negative blood film following treatment, the patient was readmitted 3weeks later with recurrent parasitaemia. Further testing for drug-resistant phenotypes and genotypes demonstrated reduced susceptibility to lumefantrine, an A675V mutation in the pfk13 gene and increased ring-stage survival, consistent with partial artemisinin resistance. The case highlights the high risk of P. falciparum treatment failure in patients with hyperparasitaemia and partial drug resistance.

Jye Travis, Kate McCarthy, Paul Chapman, Lawrence Huang, Angelica Tan, Qin Cheng, Bridget E. Barber

A 41-year-old woman presented to the emergency department with a widespread pruritic, erythematous eruption following 6weeks of kava consumption for anxiety and insomnia. The eruption began on the abdomen and progressively involved the chest, upper back and face. Laboratory investigations revealed mild derangement of liver function test results. Skin biopsy results demonstrated folliculocentric inflammation and necrosis of sebaceous glands, consistent with acute kava dermopathy. Kava, a traditional anxiolytic herbal preparation, has been implicated in both chronic and acute cutaneous reactions, including ichthyosiform and sebotropic eruptions. Its active compounds, kavalactones, are hypothesised to provoke a cytotoxic T-cell–mediated response targeting sebaceous glands. This case is notable as it occurred in an Australian woman with no travel history to the Pacific Islands—a region where kava use is prevalent. Moreover, the distinct histopathological findings, rarely documented in the literature, provide valuable diagnostic insight and serve as a visual reference for clinicians encountering this condition.

Ali Abid, Nicholas Allen, Abeer Hagelamin, Christopher Henderson, Artiene Tatian

Genomic newborn screening (gNBS) can screen for a broad range of genetic conditions, potentially enabling early treatment and improving health outcomes. However, it remains outside publicly funded programmes due to limited evidence and substantial implementation challenges. Offering gNBS in the interim as a fee-for-service option in Australia risks creating inequitable healthcare access, fragmenting care and limiting control over genomic data. Conversely, prohibiting private access may unfairly deny potential benefits to individual infants and families. This article discusses the ethical and practical implications of offering gNBS on a fee-for-service basis prior to a decision being made regarding public funding. Although fee-for-service gNBS undermines equitable access, regulated private offerings by public genomics services could mitigate some of the risks. We emphasise the need for large-scale, well-designed research studies to inform the development and equitable implementation of robust gNBS programmes within public healthcare frameworks.

Christopher Gyngell, Sebastian Lunke, Danya Vears, Zornitza L. Stark

ObjectivesTo assess the frequency of valproate prescribing for female patients of childbearing age at the Royal Children's Hospital, Melbourne, and to assess the frequency of documented discussions with these patients about the teratogenicity of valproate and the discussions or prescribing of contraception.Study DesignRetrospective audit of hospital electronic medical records data; analysis of Pharmaceutical Benefits Scheme (PBS) valproate dispensing data.Setting, Participants13- to 18-year-old girls or women prescribed valproate at the Royal Children's Hospital, Melbourne during 29 May 2022–29 May 2024; PBS valproate dispensing data for Australia for the 2023 calendar year.Main Outcome MeasuresCharacteristics of adolescent female patients prescribed valproate; documented discussions of valproate-related teratogenicity, and discussions or prescribing of contraception; population valproate prescribing rates for Australia and by state.ResultsValproate was prescribed for 245 female patients aged 13–18years during 2022–2024 (median age, 16years; interquartile range [IQR], 14–17years); the median prescribed daily dose was 600mg (IQR, 400–800mg; range, 200–2000mg). Valproate was prescribed for treating epilepsy for 221 patients (90%), including 97 (44%) with drug-resistant epilepsy; 160 patients (65%) had neurodevelopmental disabilities. Teratogenicity was discussed with 32 patients (13%), less frequently with patients with a neurodevelopmental disability (9% vs. 20%; odds ratio [OR], 0.41; 95% confidence interval [95% CI], 0.19–0.88). Contraception was discussed with 69 patients (28%); the proportion was larger for patients with neurodevelopmental disabilities (34% vs. 16%; OR, 2.66; 95% CI, 1.37–5.14). Contraception was prescribed for 50 patients (20%); the proportion was larger for patients with neurodevelopmental disabilities (25% vs. 12%; OR, 2.50; 95% CI, 1.18–5.30). The national PBS-subsidised dispensing rate during 2023 was 621 per 100,000 girls and women aged 13–18years; in Victoria it was 556 per 100,000 girls and women aged 13–18years.ConclusionDespite the risk of teratogenicity, valproate was prescribed for a considerable number of female adolescents at the Royal Children's Hospital during 2022–2024 and across Australia during 2023. Its teratogenicity was discussed with few patients, nor were discussions or prescribing contraception frequent. Contraception was more frequently discussed and prescribed for patients with neurodevelopmental disability, but teratogenicity was discussed less often.

Briana Davis, Monica S. Cooper, Michael South, Jeremy L. Freeman, Emma Macdonald-Laurs

ObjectivesTo determine how many people who die of cancer in Victoria receive palliative care and early palliative care (more than 3months before death); to assess the impact of early palliative care on the quality of end-of-life care.Study DesignRetrospective, population-based cohort study; analysis of linked Victorian Cancer Registry data and routinely collected data for inpatient, non-admitted health service and emergency department care during the 12months prior to death.Setting, ParticipantsVictorian adults who died of cancer during 1 January 2018–31 January 2023.Main Outcome MeasuresProportions of people who received palliative care (any time) or early palliative care (more than 3months prior to death); likelihood of quality of end-of-life care measures: dying outside an acute hospital; chemotherapy, two or more emergency department visits, two or more hospital admissions during final 30days of life; advance care plan at death.ResultsOf 53,305 people who died of cancer (mean age, 74.8years [standard deviation, 13.0years]; 29,527 men [55.4%]), palliative care was provided for 38,697 (72.6%); 17,409 people (32.7%) received early palliative care. The most frequent palliative care type was palliative approach to care (Z51.5 code; 33,974 people, 63.7%). The overall proportion of people who received palliative care did not change markedly during 2018–2022; the proportion who received early palliative care declined slightly, from 34.8% (95% confidence interval [CI], 33.6–35.9) to 33.0% (95% CI, 31.7–33.8). People who received early palliative care were more likely than people who received late palliative care to have an advance care plan (adjusted odds ratio [aOR], 1.46; 95% CI, 1.38–1.55) and to die outside hospital (aOR, 2.50; 95% CI, 2.37–2.64); they were less likely to have two or more of emergency department presentations (aOR, 0.75; 95% CI, 0.70–0.81), two or more hospital admissions (aOR, 0.58; 95% CI, 0.55–0.61) or chemotherapy (aOR, 0.51; 95% CI, 0.47–0.55) during their final 30days of life.Conclusion72.6% of people who died of cancer in Victoria during 2018–2023 had received palliative care, but only 33% had received it early. End-of-life care may be improved by providing palliative care early. The low early palliative care rate, despite the potential for improved outcomes for people who receive it, indicates that action is needed.

Chris Schilling, Olivia Wawryk, Anna Collins, Vijaya Sundararajan, Brian H. Le, Jennifer Philip

ObjectivesTo determine whether ceasing acetylcysteine treatment for adults with acute paracetamol overdose after at least 12h of the two-bag acetylcysteine regimen is non-inferior to providing the full 20-h two-bag regimen.Study DesignOpen label, non-inferiority randomised controlled trial.SettingEmergency departments of six Australian metropolitan hospitals (four in Melbourne, two in Sydney), 1 December 2019–31 July 2024.ParticipantsAdults who required acetylcysteine treatment following single or staggered paracetamol ingestions whose serum alanine transaminase (ALT) level was below 40IU/L on presentation, and whose ALT levels were below 40IU/L and serum paracetamol concentrations below 20mg/L after 12 h of acetylcysteine treatment.InterventionControl group (standard care): two-bag intravenous acetylcysteine regimen (200mg/kg over 4h, followed by 100mg/kg over 16h). Intervention group: Acetylcysteine stopped at least 12h after treatment initiation and the 20-h infusion period completed with intravenous compound sodium lactate.Main Outcome MeasuresDifference in ALT level between presentation and 20h after acetylcysteine treatment initiation; non-inferiority was defined as the upper limit of the 95% confidence interval (CI) of the difference between median changes in ALT level for the intervention and control groups being less than 3IU/L.ResultsOf 2830 people who presented with paracetamol overdose, 860 received acetylcysteine treatment; 186 people who met both the presentation and 12-h acetylcysteine treatment blood test inclusion criteria (median age, 17years; interquartile range [IQR], 16–23years; 162 women [87%]) were randomly assigned to the intervention (93 participants) and control groups (93 participants). Median acetylcysteine infusion time in the intervention group was 13h (IQR, 13–13 h). The median change in ALT level between arrival and 20h after starting intravenous acetylcysteine treatment was similar for the intervention (−1IU/L; IQR, −4 to 1IU/L) and control groups (0IU/L; IQR, −2 to 2IU/L); the difference in median change (−1IU/L; 95% CI, −2 to 1IU/L) was consistent with the non-inferiority criterion. No patients developed hepatic injury or hepatotoxicity.ConclusionAn abbreviated acetylcysteine treatment regimen was non-inferior to the standard 20-h two-bag regimen for people with paracetamol overdose who were at low risk of hepatic failure.Trial RegistrationACTRN12619001549112 (prospective)

Anselm Wong, Richard McNulty, Sarah E. Hodgson, Naren Gunja, Andis Graudins

ObjectivesTo assess the prevalence, characteristics and outcomes of health impairment notifications to the Australian Health Practitioner Regulation Agency (Ahpra) and to assess the influence of doctor age, sex, specialty, practice location and country of training on the incidence of health impairment notifications.Study DesignRetrospective cohort study; analysis of linked de-identified Ahpra medical register and health impairment notifications data.Setting, ParticipantsAll doctors registered to practise in Australia (except New South Wales) for whom notifications of concerns about physical or mental illness, cognitive decline, substance use disorder or other impairment to safely practising medicine were received by Ahpra during 1 July 2012–30 June 2022.Main Outcome MeasuresHealth impairment notifications, overall and by notification type and specialty; influence of doctors' characteristics on the incidence of notifications.ResultsDuring 2012–2022, 112,677 doctors were registered to practise in Australia (other than New South Wales). A total of 1732 health impairment notifications were recorded, including at least one notification for 1258 doctors (1.1%). In multivariable analyses, the incidence of health impairment notifications was higher for male than female doctors (adjusted incidence rate ratio [aIRR], 1.45; 95% confidence interval [CI], 1.26–1.67), for doctors aged 70years or older than for those aged 30–39years (aIRR, 2.92; 95% CI, 2.30–3.70) and for doctors in regional (aIRR, 1.33; 95% CI, 1.12–1.58), rural (aIRR, 1.27; 95% CI, 1.03–1.57) and remote areas (aIRR, 1.55; 95% CI, 1.03–2.33) than in metropolitan areas. Among doctors with specialist qualifications, the incidence of notifications was higher for psychiatrists than internal medicine physicians (aIRR, 2.28; 95% CI, 1.62–3.21) and the incidence of substance use notifications was highest for anaesthetists (vs. internal medicine physicians: aIRR, 2.83; 95% CI, 1.66–4.83). Compared with doctors who trained in Australia, doctors who trained in non-comparable jurisdictions were less likely to be subjects of health impairment notifications (aIRR, 0.53; 95% CI, 0.43–0.64). Of 1708 notifications with final Ahpra determinations, 367 (21.5%) resulted in practice restrictions or removal from practice.ConclusionsHealth impairment notifications are infrequent but can have serious consequences for doctors. The incidence of health impairment notifications is influenced by doctor age, sex, specialty and location. Specific measures that take these factors into account could support workplace health and safety for doctors and protect patients from harm.

Marie M. Bismark, Dilanka Hettiarachchi, Martin Fletcher, Owen Bradfield, Anu Tayal, Yamna Taouk

ObjectivesTo assess the effectiveness of Strengthening Care for Children (SC4C) for reducing the number of referrals by general practitioners of patients under 18years of age to hospital services.Study DesignStepped-wedge cluster randomised trial; data collected for up to 16months after the intervention.SettingGeneral practices in North Western Melbourne and Central and Eastern Sydney primary health networks, 1 May 2021–30 September 2023.ParticipantsGeneral practitioners who worked at least two clinical sessions each week, saw patients under 18years of age, and for whom at least 1 month of referrals data during the control period were available; families of people under 18years attending these practices.InterventionWeekly (6 months) then fortnightly (6 months) general practitioner–paediatrician co-consultations; monthly paediatrician-led case discussions; weekday phone and email support by paediatricians.Main Outcome MeasuresProportion of general practitioner visits in which patients were referred to publicly funded hospital outpatient clinics or emergency departments (patient level), overall and by baseline referral rate. Secondary outcomes: Referrals after completion of the intervention; general practitioner confidence regarding child health care; low value care for frequent childhood conditions; family preference for general practitioner or paediatrician care.ResultsOne hundred and thirty participating general practitioners from 22 general practices conducted 50,101 consultations during the control period; 125 general practitioners from 21 general practices received the intervention and undertook 96,804 consultations. Patients were referred to hospitals in 2.3% of control period consultations and 1.9% of intervention period consultations (risk difference, −0.34 [95% confidence interval {CI}, −0.69 to 0.004] percentage points). Among general practitioners with high referral rates at baseline (5% or higher), patients were referred to hospital outpatient or emergency department in 7.3% of control period consultations and in 3.0% of intervention period consultations (risk difference, −4.28 [95% CI, −6.59 to −1.97] percentage points); the referral rate was also lower after the intervention period (sustainability vs. control periods: 2.9% vs. 5.8%; risk difference, −2.92 [95% CI, −5.36 to −0.48] percentage points). The proportions of general practitioners confident about their knowledge and skills regarding child health care were larger during the intervention than the control period. Quality of care and family preference for general practitioner-led care for their children remained high across the study. No adverse events were recorded.ConclusionStrengthening primary care for children reduces the frequency of hospital referrals of children by general practitioners with high referral rates, increases rates of general practitioner confidence about caring for children and maintains family preference for general practitioner-led care.Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12620001299998 (prospective)

Harriet Hiscock · Cecilia Moore · Sonia Khano · Lena A. Sanci · Kim M. Dalziel · Gary Freed · Douglas I. R. Boyle · Tammy Meyers Morris · Siaw-Teng Liaw · Jane Le · Yvonne A. Zurynski · Susan Woolfenden · Raghu Lingam

Hereditary pancreatitis causes severe early-onset pain and hospitalisation. In 15 Australian patients undergoing total pancreatectomy and islet auto transplantation (TPIAT), we observed a marked reduction in hospital admissions, inpatient days and emergency visits, complete analgesic cessation by 24 months and durable insulin independence in nearly half of the patients. These findings highlight TPIAT’s potential to improve quality of life and reduce healthcare burden. Our programme aims to build evidence to support public funding and ensure equitable access to this procedure.

Merle Weetra, Denghao Wu, Sanjeev Khurana, Bhanu Mariyappa, Jenny Harrington, Tom Loudovaris, Gordon Thomas, Henry C. C. Pleass, Alex Brown, Thomas W. Kay, Christopher J. Drogemuller, David J. Torpy, Richard Couper, John Chen, Patrick T. Coates

In a population cohort of 44,216 adolescent girls, about 73.5% of those who became pregnant were known to child protection services. Exposure to higher levels of child protection response was associated with increased cumulative incidence and an earlier age of pregnancy.

Oliver Watkeys, Kimberlie Dean, Kristin R. Laurens, Stacy Tzoumakis, Vaughan J. Carr, Melissa J. Green

Adam Morton

Michael Do, Annabelle Hayes, Malgorzata Brzozowska

Daniel Mogg, Michael H. Levy

Lodge C, Dai X, Laing IA, et al. Evidence from Australian cohort studies about asthma trajectories and transitions across the life course: a narrative review. Med J Aust 2025; 223 (10 Suppl): S24–S31. https://doi.org/10.5694/mja2.70086. In Box 3, the second data row should read as follows: Study Start year Age at start, in years (enrollees) Age at follow-up Wheeze/asthma definition Lung function assessed Biological samples Busselton Health studies33 1966 7 to > 70 (20 000) 20 to > 90 Standard asthma questions. Spirometry: forced oscillation technique (all studies) airway responsiveness (selected studies). Blood at 21 surveys that collected asthma data.