Volume 224 Issue 4

We describe the clinical presentation, laboratory findings and complications of severe paediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 (PIMS-TS), also known as multisystem inflammatory syndrome in children in a 16-year-old female diagnosed in June 2025. This case highlights the importance of prompt diagnosis of PIMS-TS in the post-coronavirus disease 2019 pandemic era to ensure timely and appropriate management.

Rana Sawires, Anneke Engwerda, Mehyar Khair Baik, Philip N. Britton, David P. Burgner

Voluntary assisted dying (VAD) provides a pathway to organ donation distinct from typical pathways requiring withdrawal of cardiorespiratory support. Patients considering VAD now have the option to be donors and benefit others through donation and transplantation. This is not widely known in the community. In this article, we consider the ethical issues in advising VAD patients about the option of organ donation. We balance patient autonomy against the risks of coercion and conflict of interest. All eligible patients should be advised about the option so they can make an informed decision. However, the timing and source of information are critical in ensuring that patients can make a well-considered, ethically sound choice. We propose a pathway for provision of information about organ donation for patients considering VAD.

Leo Nunnink, Melanie Jansen, Fabian Jaramillo, Wade Stedman

Organ donation after voluntary assisted dying (VAD) is increasingly undertaken in jurisdictions where it is legally permissible, including Australia, although previously all reported cases involved intravenous administration of the life-ending substance. A 55-year-old woman in Victoria has become the first known person to have successfully donated organs and tissues after self-administration of an oral substance, despite initial uncertainty about feasibility due to the unpredictable time to death (agonal phase). With Victorian legislation requiring self-administration as the default, this case provides a precedent, opening the possibility of donation for others in this majority VAD cohort where oral administration is obligatory.

Joanne Kantianis, Helen I. Opdam, Rohit L. D'Costa

This commentary examines the cancellation of the author's keynote talk at a scientific conference in 2023, which referenced her work with Médecins Sans Frontières in Palestine. It evaluates challenges and perceived barriers to medical organisations and individuals speaking at the intersection of politics and health. As powerful bodies and individuals trained in rigorous interpretation of information and challenging communication, with a disproportionate amount of social and political capital, healthcare professionals and medical organisations should at least permit, and aspire to lead, a humane and nuanced discourse on current affairs that deeply impact health. Avoiding silence, and silencing of clinicians, can be an important contributor to humanisation, which intersects with the provision of equitable and safe access to health.

Natalie Thurtle

Introduction: Older people face higher risks of medicine-related harm due to polypharmacy and the use of potentially inappropriate medicines. Current treatment guidelines rarely specify when to stop medicines, leading to medicines often being continued indefinitely without a clear deprescribing plan. While deprescribing guidelines exist for some medicine classes, limited guidance is a major barrier to deprescribing. These new guidelines address this gap by providing structured recommendations that complement more detailed drug-specific deprescribing guidance, disease-specific therapeutic guidelines and non-pharmacological management resources. These guidelines were developed by a team of 72 experts, including consumer representatives, and were further shaped by feedback from public consultation and independent reviewers.Main Recommendations: The guidelines are intended for all healthcare professionals involved in prescribing, dispensing or administering medicines to older people. The guidelines specifically address polypharmacy and medicines commonly dispensed for regular use in people aged ≥ 65 years, as well as other medicines where there is evidence to consider deprescribing in this cohort. The guidelines provide 185 consensus-based recommendations and 70 good practice statements, covering both specific medicine categories and general deprescribing principles. The guidelines are structured into four areas: (1) when to deprescribe; (2) ongoing treatment needs; (3) how to deprescribe; and (4) monitoring requirements.Changes in Care as a Result of the Guideline: This guideline emphasises deprescribing as an integral part of the prescribing continuum. Applying a deprescribing approach encourages prescribers to consider the ongoing need for a medicine each time a prescription is re-issued, to balance benefits and harms as they evolve over time, and to ensure treatment decisions reflect an individual's goals through shared decision-making. The guideline was developed based on currently available evidence for deprescribing and expert multidisciplinary and consumer input. It supports health professionals in reviewing regular medicines, minimising harm and planning ongoing treatment or monitoring. The detailed guideline is available at https://deprescribing.com.

Stephen Tucker, John D. G. Watson, Donna Wellins, Tim Whitmore, Christopher Etherton-Beer, Amy T. Page

Australia has been at the forefront of innovation and implementation of cervical cancer control and is predicted to eliminate cervical cancer by 2035, the first country to achieve elimination using active measures. This is a result of Australia being an early adopter of universal human papillomavirus (HPV) vaccination and early transition to a primary HPV-based cervical screening program. However, to ensure timely and equitable elimination, disparities in coverage among underserved populations must be addressed, and recent declines in vaccination and screening uptake must be reversed. Improved routine data linkages are required to ensure gaps in participation in subpopulations can be identified. Primary health providers have an important role in checking vaccination and screening status and offering vaccination catch-up or screening as appropriate. A universal option of self-collection of an HPV sample for all screen-eligible people has increased acceptability overall, but further innovative and flexible models of service delivery are required to ensure equitable access for all. Australia has also played an important role in cervical cancer control globally and was a co-sponsor of the 2020 World Health Assembly resolution to accelerate the global elimination of cervical cancer as a public health problem. In the Indo-Pacific region, regional frameworks have been developed to advance strategic actions to progress implementation of the global strategy. The Elimination Partnership in the Indo-Pacific for Cervical Cancer (EPICC), a major initiative supported by the Australian Government and the Minderoo Foundation, provides tailored support to countries, considering local needs and priorities.

Susan Yuill, Carol Naidu, Megan Smith, Deborah Bateson, Marion Saville, Boniface Damutalau, Karen Canfell

Objectives To evaluate the uptake of a new 60-day dispensing policy for antihypertensive medicines and estimated cost savings compared with conventional 30-day dispensing; and to explore general practitioner and pharmacist perspectives on the new policy. Study Design Mixed methods design; analysis of Pharmaceutical Benefits Scheme (PBS) dispensing claims from 1 September 2023 to 30 April 2025; and semi-structured interviews with 20 general practitioners and four pharmacists from 13 June 2024 to 24 September 2024 to gauge their perspectives on 60-day dispensing. Setting, Participants General practitioners and pharmacists practising in New South Wales, Victoria and Queensland, Australia. Main Outcome Measure Antihypertensive prescription volumes; patient and government cost savings; and perceptions of the policy from general practitioners and pharmacists. Results The 60-day antihypertensive prescription volume increased from 75,500 to 877,700 over 20months, accounting for 21.2% of all antihypertensive dispensing by 30 April 2025. We estimate the total cost savings for patients were up to ~$65 million, and the government saved ~$87 million and paid pharmacies ~$86.7 million via the Additional Community Supply Support (ACSS) payment program, with a net effect of ~$0.3 million. In interviews, general practitioners indicated varied utilisation of 60-day prescriptions, with some actively providing 60-day prescriptions, but some rarely or not at all. Barriers included keeping abreast of eligible and ineligible medicines for 60-day prescriptions and perceived resistance from pharmacists. Pharmacists were concerned about incorrect dispensing and potential medication shortages. Conclusion At 20months after the introduction of the new policy, 21.2% of antihypertensive prescriptions were for 60-day dispensing. The slow uptake is likely due to low uptake among general practitioners and resistance from pharmacists. The 60-day policy has demonstrated substantial financial savings for patients. If uptake of 60-day dispensing increased to 50%, annual savings from antihypertensive medicines could rise to up to ~$165 million for patients and ~$11.6 million for the government.

Tian Wang, Huy L. Nguyen, Isabella Tan, Dean S. Picone, Emily Atkins, Sonali R. Gnanenthiran, Michael O. Falster, Sallie-Anne Pearson, Anthony Rodgers, Aletta E. Schutte

Objective To examine the awareness, usage and perceptions of doxycycline post-exposure prophylaxis (doxyPEP) for sexually transmitted infection (STI) prevention among gay and bisexual men and transgender (trans) and gender diverse people in Australia. Design Cross-sectional online survey. Setting, Participants National multi-site survey in Australia from 1 July 2024 to 30 November 2024, recruiting from 13 sexual health and community clinics, 6 general practices, social media, dating applications, and university portals. Gay and bisexual men and trans and gender diverse people aged ≥18years living in Australia were included in the study. Main Outcome Measures DoxyPEP awareness, ever use, recent use (past 12months), dosage regimens, sourcing methods and planned future use. Results Among 2095 participants, half (1080/2095, 51.6%) had heard of doxyPEP. Of those aware, 323/1080 (29.9%) had ever used doxyPEP, and 306/1080 (28.3%) were recent users. DoxyPEP awareness and usage varied by HIV status and pre-exposure prophylaxis (PrEP) use (p<0.0001). Nearly two-thirds of users had taken the recommended 200mg within 72h after sex (205/323, 63.5%). Among recent users, 29/306 (9.5%) reported recent syphilis diagnoses, and 85/306 (27.8%) had ≥2 STI diagnoses in the past 12months. Of those who had ever used doxyPEP, 135/323 (41.8%) obtained prescriptions from clinicians, 17/323 (5.3%) obtained it online, and 28/323 (8.7%) purchased it in person overseas without a prescription. Of those aware of doxyPEP, 490/1080 (45.4%) planned to use doxyPEP in the next 12months, primarily to prevent chlamydia (460/490, 93.9%), gonorrhoea (422/490, 86.1%) or syphilis (386/490, 78.8%). Some intended to prevent Mycoplasma genitalium (92/490, 18.8%) or mpox (36/490, 7.4%). Among non-users, 306/756 (40.5%) worried about antibiotic resistance. Conclusions DoxyPEP use was happening quickly but often involved non-recommended regimens and unsupervised sourcing. Urgent educational interventions and improved clinical access are needed for safe implementation.

Catriona S. Bradshaw, Dash Heath-Paynter, Benjamin Riley, Daniel Grace, Fabian Y. S. Kong, Eric P. F. Chow

Objective To support a nationally representative group of Australians to make informed, reasoned recommendations on the use of genomics in newborn screening programmes. Design Hybrid Citizens’ Jury method. Setting, Participants Thirty Australian adults recruited by random ballot invitation and stratified selection against population-based demographic targets of age, sex, ancestry, highest level of education, location of residence (state/territory, urban/non-urban), experience of disability and parent/non-parent. Main Outcome Measures Jury recommendations with reasons. Results The jury made 11 recommendations. The jury agreed whole genome sequencing could be used in the programme, but only if conditions were met regarding national consistency, benefit, Australian Government oversight, consent, reporting to parents, data protection, supporting parents and the healthcare system, and parent and public education. All of these conditions were agreed by consensus, except reporting to parents and parent and public education, where there was a supermajority (24/30) in agreement and minority dissent. The jury were split on Recommendation 11: how much genomic data should be extracted and retained. Nine jurors supported whole genome sequencing only if data extraction and retention were limited to interpretable, actionable genetic information; 21 jurors supported a more expansive approach. Conclusions To maintain public trust in Australian newborn screening, programmes should take a more conservative approach to data extraction and storage until concerns are addressed and safeguarding conditions implemented. Jurors' key concerns include identifiability of genomic data, risk of data misuse and potential to undermine trust and participation in newborn screening.

Emma Frost, Zornitza L. Stark, Kristen Nowak, Louise Healy, Sarah Norris, Stacy M. Carter

Objectives To evaluate the cost-effectiveness of donanemab, an anti-amyloid-β monoclonal antibody recently approved in Australia, for treating early-stage Alzheimer disease with confirmed amyloid-β pathology from healthcare system and societal perspectives. Design A Markov microsimulation model simulating long-term Alzheimer disease progression, treatment costs and health outcomes for donanemab compared with standard care. Setting, Participants Australian healthcare context, applying published clinical and economic inputs. A hypothetical cohort of people with early symptomatic Alzheimer disease, consistent with TRAILBLAZER-ALZ eligibility criteria: mean age 75years, amyloid-β-positive, with mild cognitive impairment or mild dementia because of Alzheimer disease and excluding individuals with APOEE4 homozygotes, in line with the Australian labelling. Donanemab administered every 4weeks with magnetic resonance imaging (MRI)-based amyloid-β-related imaging abnormalities monitoring and treatment suspension upon amyloid-β clearance or progression to severe Alzheimer disease, compared with standard care. Main Outcome Measures Incremental costs, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs). Secondary analyses included sensitivity and distributional equity analyses. Results Donanemab increased total healthcare costs ($300,689 vs. $178,121) and societal costs ($389,113 vs. $283,618) compared with standard care per capita, while improving health outcomes (4.38 vs. 4.01 QALYs) per capita. The ICER was $342,424 per QALY from the healthcare perspective and $294,701 per QALY from the societal perspective, exceeding frequently cited Australian willingness-to-pay thresholds. Sensitivity analyses identified drug cost and efficacy as key drivers of uncertainty. Distributional analysis suggested inequitable health gains by remoteness because of differences in diagnostic and treatment infrastructure. Conclusion Donanemab provides clinical benefits but is unlikely to be cost-effective under current Australian thresholds. Policymakers should balance economic evidence with unmet need, equity considerations and healthcare sustainability when making reimbursement decisions. Further research using real-world evidence and disaggregated analyses by geography and socioeconomic status is warranted.

Lan Gao, Rosie Watson, Nawaf Yassi

Thomas Bradley

Sav Zwickl, Ada S. Cheung

Mark Robinson, Gerry McCartney

Fei Zhang, Zhong Wang

Joanna Y. Gong, Emily D. Williams, Agus Salim, Spiros Fourlanos, Jonathan E. Shaw, Dianna J. Magliano

Danielle M. Muscat, Kirsten J. McCaffery, Heather L. Shepherd, Marguerite Tracy