Volume 224 Issue 5

Introduction This consensus statement from multidisciplinary experts and consumers across Australia provides comprehensive recommendations on the prevention and management of frailty in community-dwelling older adults. Methods The study uses a modified Delphi design. Phase I involved iterative discussion among six frailty care working groups, based on current evidence and expert opinion, to draft the statements. Phase II involved validation of each statement across two Delphi rounds conducted to determine level of agreement. Main Recommendations A lifelong approach to health promotion for frailty prevention should focus on raising awareness, annual screening (65+ years) and personalised counselling around accessible health behaviours to manage chronic comorbidities. An individualised, balanced, protein-rich diet is likely to be effective in delaying the onset of frailty. Protein–energy malnutrition and nutritional deficiencies should be identified and treated. A nutrition care plan that considers the relaxation of dietary restrictions aligned with goals of care should be planned for older adults with severe frailty. Progressive, individualised and ongoing exercise should be a combination of aerobic and resistance exercise, and balance and functional training tailored to frailty level and supervised by professionals. Social prescribing for older adults should be co-designed with a link worker to support meaningful, accessible and culturally appropriate activities that foster social engagement, with plans customised to the individual's frailty level. A comprehensive, multidisciplinary medication review tailored to the older adult's health status, preferences and frailty degree helps optimise medication use, minimise harm and support functional independence across all stages of frailty. Older adults with severe frailty need a regularly reviewed, personalised care plan, which involves carers in decision-making, supports advance care planning and ensures high-quality end-of-life care. Changes in Management Informed by This Statement The consensus statements introduce an integrated, evidence-informed and consumer-focused framework to guide healthcare professionals in delivering personalised and effective care for community-dwelling older adults living with or at risk of frailty.

Lisa Kouladjian O’Donnell, Marc Sim, Michelle Miller, Peta Dampney, Pazit Levinger, Shannon King, Ruth E. Hubbard, on behalf of the Australian Frailty Network Working Group

Introduction Patent foramen ovale (PFO) is implicated in 25%–50% of cryptogenic strokes in patients aged <60years. Recent clinical trials demonstrated the benefit of PFO closure in selected patients. However, there is considerable variability in Australian and New Zealand clinical practice regarding investigation and management approaches. A multidisciplinary consensus group comprising stroke neurologists and an interventional cardiologist from major centres employed a modified nominal group technique to develop evidence-based recommendations for standardising PFO-associated stroke management. Main Recommendations Twelve recommendations were developed across three domains. For patient selection: Universal PFO screening for cryptogenic stroke patients aged ≤60years, with selective screening for patients aged >60years with embolic stroke of undetermined source, absent vascular risk factors and excluded atrial fibrillation. For diagnostic investigations: Transcranial Doppler (TCD) bubble study as preferred first-line screening where available, with transthoracic echocardiography as an alternative when TCD is unavailable and transoesophageal echocardiography for confirmation before closure consideration. For treatment decisions: Incorporation of the PFO-Associated Stroke Causal Likelihood (PASCAL) classification system rather than the Risk of Paradoxical Embolism (RoPE) score alone, consideration of TCD grading results for risk stratification and mandatory multidisciplinary heart–brain team evaluation for all closure decisions. Changes in Management as a Result of This Consensus Statement These recommendations will standardise practice through enhanced TCD service provision, structured heart–brain team development and evidence-based patient selection using the PASCAL classification. The emphasis on TCD as first-line screening represents a departure from traditional transthoracic echocardiography-based approaches. Implementation will improve patient outcomes through appropriate intervention in suitable candidates while avoiding unnecessary procedures in those unlikely to benefit, thereby promoting equitable access to optimal PFO management across Australia and New Zealand.

Brian R. Chambers, Lauren M. Sanders, Amanda Gilligan, Carlos Garcia-Esperon, Jan Ho, John Fink, Matias Yudi, Matthew Lee-Archer, Vimal Stanislaus, Andrew A. Wong

Primary hyperparathyroidism has a prevalence of around 1% in the general population. Diagnosis requires biochemical testing of serum (for calcium and parathyroid hormone) and urine (for calcium excretion), as well as wider screening for complications including osteoporosis, renal disease, abdominal symptoms and neuropsychiatric disturbance. In selected individuals, genetic testing is a key consideration because up to 10% have hereditary primary hyperparathyroidism. Surgery is curative, with a minimally invasive approach preferred after identifying the abnormal parathyroid glands on preoperative imaging. Uncertainty surrounds the diagnosis of non-classical manifestations of primary hyperparathyroidism, preoperative imaging algorithms and management pathways in normocalcaemic primary hyperparathyroidism.

Elizabeth Wootton, Sunita M. C. De Sousa, Richard L. Prince, Donald S. A. McLeod, David A. Pattison, Mathis Grossmann

Metabolic (dysfunction)-associated fatty liver disease (MAFLD) or metabolic (dysfunction)-associated steatotic liver disease (MASLD) is the most common and fastest growing cause of chronic liver disease worldwide. There has been a substantial increase in the epidemiological research regarding MASLD/MAFLD originating from Australia since 2020. This narrative review summarises these pivotal epidemiological studies investigating the disease prevalence, natural history, prognostication and management of this condition. The Australian literature demonstrates the prevalence to be between one-third and two-fifths of adults affected, depending on nomenclature, with a heightened risk of cardiovascular disease irrespective of terminology. Current local data support guideline-based disease staging with non-invasive tests of fibrosis and the management continues to centre on diet and lifestyle interventions, with directed therapy on the horizon.

Karl Vaz, Daniel Clayton-Chubb, William W. Kemp, Stuart K. Roberts, Ammar Majeed

Objectives To explore the perceptions of Indigenous South Australian adults regarding their oral and general health, social and emotional well-being and dental care experiences. Study Design Qualitative study; interviews with Indigenous South Australian adults involved in a non-randomised implementation and service-delivery project evaluating provision of culturally safe, comprehensive dental care. Study governance was provided by an Indigenous Oral Health Unit Reference Group with Indigenous leadership to centre cultural authority and cultural safety across all study dimensions. Participants Setting Semi-structured interviews were conducted with 136 Indigenous South Australian participants at a location of their choosing (e.g., their home, a community centre, a research facility), which were held at baseline (1 July 2022–15 December 2023) and 12-month follow-up (1 March 2024–31 March 2025). Intervention The overarching study consisted of a pre–post assessment of oral health embedded in routine dental care with oral epidemiological examinations and assessment of systemic health biomarkers (blood glucose, inflammation, cholesterol, kidney function). This was followed by semi-structured interviews at 12-month follow-up. Main Outcome Measure Qualitative outcomes—participant experiences, understandings and recommendations around supporting oral health, social and emotional well-being and culturally safe dental care for Indigenous South Australians. Results Reflexive thematic analysis was used to analyse interview data, from which five themes were developed. Participants described the importance of oral health for overall health, aesthetic and functional impacts and judgement and discrimination related to poor oral health, all of which were linked to social and emotional well-being. Culturally safe care that includes oral health assessments alongside assessments of biomarkers for systemic health were suggested to promote self-confidence, reduce feelings of shame and empower communities. Conclusion This study highlights the need to incorporate holistic approaches in promoting Indigenous oral and systemic health and in supporting social and emotional well-being. Trial Registration Australian New Zealand Clinical Trials Registry (ACTRN12626000046303; retrospectively registered)

Ria Aiyar, Sonia Nath, Joanne Hedges, Gina L. Guzzo, Kostas Kapellas, Alexander Pham, Emma Flanagan, Tiyanna-Marie Mastrosavas, Ebony Wallace, Lisa M. Jamieson

National linkage of the Australia and New Zealand Living Kidney Donor Registry and the Australia and New Zealand Dialysis and Transplant Registry provides the first Australian estimates of kidney failure treated with kidney replacement therapy (KRT) after living kidney donation (2004–2024). Out of 5291 donors (56,962 person-years; median follow-up, 10.96years), three donors underwent KRT (0.53 per 10,000 person-years). No events occurred within 10years of donation. Australian clinicians can now counsel and guide potential donors using local data: risk of kidney failure requiring KRT is very low, but late events warrant lifelong follow-up.

Melanie Wyld, Kate Wyburn

Objective To determine whether the screening age for atrial fibrillation (AF) should be lowered for Indigenous Australians with the goal of reducing risk of stroke and other health burdens. Study Design Systematic review of medical databases identified 24 studies reporting outcome measures: AF incidence/prevalence, age of AF occurrence/diagnosis, cardiovascular risk factors and stroke risk. Risk of bias was evaluated using the Joanna Briggs Institute quality appraisal tools. Meta-analysis of mean age of AF onset was performed. An expert panel reviewed the evidence and formed consensus recommendations regarding screening for AF for Indigenous Australians. Data Sources MEDLINE, Embase, Scopus, Cochrane, CINAHL, Australian Indigenous HealthInfoNet and grey literature. Data Synthesis The review yielded five key findings. Indigenous Australians when compared with non-Indigenous Australians have: (i) higher AF rates at every age group, and meta-analysis showed onset of AF for Indigenous people at 15.9years (95% CI, 11.5–20.4), younger than for other Australians; (ii) higher prevalence of cardiovascular risk factors; (iii) higher stroke rates (38%–47% vs. 10%–15% of all strokes occur before age of 55years), higher mortality and other adverse outcomes after stroke and the nationally age standardised risk ratio of death from AF was 1.8 for 1997–2022; (iv) less likelihood of receiving optimal treatment; and (v) greater cost of care for stroke rehabilitation. Conclusions The evidence supports an amendment to the AF guideline to opportunistically screen Indigenous Australians from at least age 55years, and when AF is found, follow guideline recommendations for management of rate, rhythm, stroke prevention and concomitant risk factors/comorbidities. Further, the logistics of care should be considered when deciding on the localised care pathway. National implementation of these recommendations should minimise missed diagnoses and ensure timely, accessible and appropriate care/treatment. Registration Prospective registration with PROSPERO (CRD42024514586) on 13 May 2024.

Kylie Gwynne

P. M. Latt, E. T. Aung, K. Maddaford, et al; DoxyAWARE Study Group. Awareness, Usage and Perceptions of Doxycycline Post‐Exposure Prophylaxis (doxyPEP) for Prevention of Sexually Transmitted Infections in Australia: Insights From a National Cross‐Sectional Survey. Medical Journal of Australia 2026; 224(4): e70180. https://onlinelibrary.wiley.com/doi/10.5694/mja2.70180. In the second paragraph of section 3.3. Uptake and Dosage Regimens, where it says ‘Only 4/323 (1.2%) took it every day (i.e., doxyPrEP), and the remainder 114/323 (35.3%) used other non-recommended regimens (3/323, 0.9%),’ it should read ‘Only 4/323 (1.2%) took it every day (i.e., doxyPrEP), and the remainder 114/323 (35.3%) used other non-recommended regimens’.

S. Yuill, C. Naidu, M. Smith, D. Bateson, M. Saville, B. Damutalau, K. Canfell. Cervical cancer elimination in Australia and the Asia Pacific: Progress and barriers. Medical Journal of Australia 2026; 224(4): e70164. https://onlinelibrary.wiley.com/doi/10.5694/mja2.70164. The affiliations for Marion Saville were out of date at the time of submission and should read: Australian Centre for the Prevention of Cervical Cancer, Melbourne, Victoria, Australia; University of Malaya, Kuala Lumpur, Malaysia.