Volume 224 Issue 6

Elevated liver function tests are commonly attributed to hepatic disease but may reflect extrahepatic pathology. We describe the case of an 18-year-old athletic woman with a 2-year history of elevated aspartate aminotransferase (AST), alanine aminotransferase (ALT) and creatine kinase (CK) levels, initially investigated extensively for hepatic causes. Despite normal liver imaging and biopsy, ongoing abnormalities prompted metabolic evaluation, leading to the diagnosis of late-onset Pompe disease. This case highlights the diagnostic challenges of rare metabolic myopathies, the importance of recognising muscle-derived aminotransferase elevation and the need for broad diagnostic consideration when standard investigations are unrevealing.

Shauna Madigan, Georgina England, Wayne Rankin

Introduction For many people entering custody, abrupt changes in alcohol or other drug use is associated with the risk of experiencing a withdrawal syndrome. Management of withdrawal from alcohol and other drugs in a custodial setting is complicated by both a limited evidence base and structural barriers to the delivery of best practice healthcare interventions to people in custody. Main Recommendations A multidisciplinary expert panel representing all Australian states and territories participated in a modified Delphi process. The process generated 22 recommendations to custodial services, health services and government for the management of withdrawal from alcohol and other drugs in custodial settings across five domains: screening for withdrawal risk; assessment of withdrawal; management of withdrawal; specific considerations for the care of First Nations people; and organisational support. Notable recommendations include using universal and timely assessment for withdrawal at reception to custody; using validated clinical tools and evidence-based interventions to assess and manage withdrawal syndromes; and ensuring that the safest location for withdrawal from alcohol or other drugs is provided. Changes in Management as a Result of the Statement This statement presents best practice standards for the management of withdrawal from alcohol and other drugs in Australian custodial settings, as informed by evidence and expert consensus. Implementing the recommendations set out in this statement will improve the quality and consistency of withdrawal care provided to people entering Australian custodial settings and reduce harms associated with incarceration for people who use alcohol and other drugs. This statement has been endorsed by the Royal Australasian College of Physicians, the Australasian Professional Society on Alcohol and Other Drugs, the National Prisons Hepatitis Network, the Pharmaceutical Society of Australia and the Australian Injecting and Illicit Drug Users League. The statement is also approved as an Accepted Clinical Resource by the Royal Australian College of General Practitioners.

Grace FitzGerald, Jocelyn Chan, Jon Cook, Mark Stoove, Michael Curtis, Suzanne Nielsen, Rebecca J. Winter, Thileepan Naren

Objectives To examine the effects of social media on future mental health problems (depressive symptoms, anxiety symptoms, poor well-being and self-harm) in adolescents aged 12–18years, overall and stratified by sex and age periods (early, middle and late adolescence).Study TypeProspective longitudinal study.SettingParticipants were recruited in 2012 through schools in Melbourne, selected using stratified random sampling. In wave 1 (2012), 1239 Grade 3 students participated and have since completed annual surveys.ParticipantsThe analysis used data up to wave 11 (2022). Participants with no data on mental health, social media and confounders were excluded, leaving a sample of 1195 (552 [46%] male participants).Main Outcome MeasuresExposure was self-reported duration of daily social media use at each wave, from waves 4 to 10 (ages 12–18years). Outcomes (self-reported depressive symptoms, anxiety symptoms, well-being, self-harm) were assessed at the subsequent annual wave, from waves 5 to 11 (ages 13–19years).ResultsAcross adolescence, >2h versus <1h of daily social media use was associated with a small increase in risk of high depressive symptoms (risk difference [RD] per 100, 6.3 [95% CI, 2.7–9.9]) and poor well-being (RD, 4.9 [95% CI, 1.1–8.6]) at the subsequent annual wave. Estimated risks for all mental health problems were greatest in early adolescence (12–13years), with the largest effects observed for high depressive symptoms in female participants (>2h vs. <1h: RD, 10.8 [95% CI, 2.7–18.9]).ConclusionsHigher levels of social media use were associated with small increases in future risk of high depressive symptoms and poor well-being across adolescence. The largest risks for all mental health problems were observed during early adolescence for both male and female participants, supporting the need to consider policies that mitigate the adverse effects of social media on the mental health of younger adolescents.

Nandita Vijayakumar, S. Ghazaleh Dashti, Louise Canterford, Susan Ellul, Anthony J. A. Parissi, Anne-Lise Goddings, Russell M. Viner, Paul Moran, Rohan Borschmann, Lisa K. Mundy, Ellie M. Robson, Susan M. Sawyer

Objectives To characterise the clinical, microbiological and economic burden of hospital-admitted, injection-related infections among incarcerated people who inject drugs. Study Type Retrospective observational cohort study. Setting Secure unit of the Princess Alexandra Hospital, Brisbane, Australia. Participants Adults incarcerated in Queensland prisons who were admitted to hospital with an injection-related infection between 1 July 2019 and 30 June 2023. Main Outcome Measures Types of injection-related infection, microbiological findings, requirement for surgical or radiological source control, hospital length of stay and inpatient healthcare costs. Results There were 321 hospital admissions for injection-related infection among 265 patients, accounting for 282 unique infections. Most patients were male (241; 90.9%), with a mean age of 33years (standard deviation [SD], 7.4years), and 76 (28.7%) identified as First Nations. The most frequent infections were soft tissue infections (77/282; 27.3%), acute hepatitis C (64/282; 22.7%) and cellulitis (43/282; 15.2%). Surgical or radiological source control was required in 95 infections (34.0%), and infectious diseases consultation occurred in 130 infections (46.1%). Among 39 true-positive blood cultures, Staphylococcus aureus was identified in 17 (43.6%), Burkholderia species in 10 (25.6%) and non-tuberculous Mycobacterium species in 3 (7.7%). Among the 218 non-acute hepatitis C infections, 50 (22.9%) were hepatitis C virus (HCV) RNA positive. Overall, HCV RNA was present in 114 of 282 infections (40.4%). The total inflation-adjusted inpatient cost was $8.39 million, with a median cost per infection of $11,602 (interquartile range, $7426–$34,544). Conclusion Injection-related infections among incarcerated people who inject drugs were associated with substantial morbidity and healthcare costs in this large hospital cohort. A wide clinical spectrum was observed, including atypical pathogens, and clinically overt acute hepatitis C requiring hospital admission. These findings describe a significant burden of preventable disease in custodial settings and support the introduction of established primary prevention and harm-reduction interventions in prisons.

Andrew Palmer, Matthew Carter, Jeremy Yeo, Cecilia Shim, Jason Connor, Jeremy Hayllar, Gerald Holtmann, Naomi Moy, Elliott G. Playford, Naomi Runnegar, Paul J. Clark

Objectives To report patterns of asthma control, medications and healthcare utilisation in Australian adults with asthma in 2021, and assess changes since a similar survey in 2012. Study Type Cross-sectional web-based survey (February–March 2021; n=5427), compared with a similar 2012 survey (n=2686). Setting/Participants Adults (≥18years) with asthma, recruited from large web-based panels, with enrolment stratified by age group, gender and state/territory. Main Outcome Measures Asthma control test (ACT), healthcare utilisation and medications. Results Median age was 46years; 59% of participants reported female gender. Compared with 2012, fewer participants had well-controlled symptoms (ACT≥20: 2021, 48.0%; 2012, 54.4%; p<0.001), and more had very poorly controlled symptoms (ACT 5–15: 2021, 26.8%; 2012, 22.9%; p<0.001). Urgent asthma healthcare had increased (2021, 37.9%; 2012, 28.6%; odds ratio 1.53 [95% confidence interval, 1.37–1.69]; p<0.001). Inhaled corticosteroid (ICS) use in the previous year was similar (2021, 60.9%; 2012, 60.8%) but adherence was lower (p<0.001). Fewer participants had good symptom control while taking little/no ICS (2021, 33.4%; 2012, 40.1%), and more had uncontrolled symptoms with little/no ICS (2021, 38.1%; 2012, 25.6%; p<0.001); among the latter group, urgent healthcare utilisation had increased (2021, 63.5%; 2012, 41.2%; p<0.001). In 2021, 28.7% reported using oral corticosteroids for asthma in the previous year; only 42.0% of ICS users recalled their inhaler technique having been checked in the past 12months. Overuse of short-acting beta2-agonists was common: 56.3% adults obtained ≥3 inhalers in the previous year, and 10.5% obtained ≥12 inhalers. For symptom relief in the previous 4weeks, only 13.3% adults reported using an anti-inflammatory reliever (ICS–formoterol). Conclusion Our comparison of these two large nationally stratified sample surveys demonstrates significant worsening of key asthma indicators between 2012 and 2021, including worse symptom control and urgent healthcare use, but also indicates opportunities for improvement. The findings highlight an urgent need for system-wide implementation of the 2025 Australian asthma guidelines to reduce preventable morbidity. Trial Registration ACTRN12620000977976p

Helen K. Reddel, Maria R. Ampon, Leanne M. Poulos, Sharon R. Davis, Brett G. Toelle, Guy B. Marks, Taehoon Lee

Objectives To examine two decades of Australian expenditure trends across components of primary health and to assess whether recent expenditure changes have been equitably distributed. Study Type Descriptive modelling using standardised framework for classifying primary care expenditure. Setting Australian public and private health expenditure data (2002–03 to 2022–23) were disaggregated into: broad primary health care services (Tier A); direct primary care, predominantly funding general practice (Tier B); and funding for enhanced primary care for people with greater needs (Tier C). Distributional analysis was conducted across geographies. Participants No individual participants; analysis used aggregated health expenditure data across 327 Statistical Area Level 3 geographies. Main Outcome Measures Proportions of total and public expenditure allocated to each tier; equity in public Tier B and Tier C spending across areas, assessed using standardised slope indices. Results The share of total health spending allocated to primary care declined over the period. Tier A spending declined from 36.3% to 33.0% of total health spending; Tier B fell more sharply from 8.0% to 5.5%; and Tier C remained flat at 0.7%. Public spending trends were similar, but declines were more muted, with Tier C unchanged at 1.0%. Public spending on Tier B was 13% higher in the most disadvantaged areas than in the most advantaged areas in 2013–14; by 2023–24, this declined to 7%. Public Tier C spending remained progressive at 35% higher in the most disadvantaged areas, but decreased from 51% over the decade. Exploratory multivariate analyses suggested that Tier C spending was more redistributive than Tier B after accounting for need. Conclusions Data indicate that primary care has declined as a funding priority in relative terms in Australia, and investment in high-value care has remained stagnant and appears increasingly less redistributive. These patterns may have implications for health equity.

Rafal Chomik, Shona M. Bates, Michael Wright

Objective To examine changes in rates of primary care patients seeing multiple prescribers and characteristics of patients who ceased seeing multiple prescribers for monitored medicines after voluntary implementation of the Victorian prescription drug monitoring program (PDMP). Study Design Controlled interrupted time series analysis of primary care electronic medical records. Setting A total of 562 general practices across three Victorian healthcare networks (Monash Health, Peninsula Health, Eastern Health). Patients People prescribed at least one PDMP-monitored medicine (e.g., opioids, benzodiazepines) and/or non-monitored psychotropic medicines (e.g., antidepressants, antipsychotics) between 1 January 2017 and 30 June 2023. Intervention Voluntary (1 April 2019) and mandatory (1 April 2020) implementation of the Victorian PDMP. Main Outcome Measures Changes in the monthly rate of people seeing multiple prescribers (defined as four or more prescribers) following PDMP implementation for monitored medicines, with non-monitored medicines used as a control; characteristics of people who ceased seeing multiple prescribers for monitored medicines following PDMP implementation. Results Following voluntary PDMP implementation (1 April 2019), there was a significant reduction in the differential step and trend changes in the rates of seeing multiple prescribers between people prescribed monitored and non-monitored medicines (differential step change: β, −3.55 [95% confidence interval (CI), −5.08 to −2.03]; differential trend change: β, −0.29 [95% CI, −0.46 to −0.12]). Following mandatory PDMP implementation (1 April 2020), there was no significant step change difference. However, there was an increase in the differential trend change in the rate of seeing multiple prescribers between those prescribed monitored and non-monitored medicines (differential trend change: β, 0.21 [95% CI, 0.05–0.37]; p=0.009). Logistic regression revealed that older age (95% CI, 1.39–1.75), male gender (95% CI, 1.09–1.25), metropolitan residence (95% CI, 1.04 and 1.23) and substance use disorder diagnosis (95% CI, 1.07–1.28) were associated with significantly higher odds of seeing multiple prescribers before PDMP implementation. Conclusions Implementation of the PDMP was associated with meaningful reductions in people accessing monitored medicines from four or more prescribers.

Louisa Picco, Monica Jung, Grant Russell, Samanta Lalic, Mahbod A. Fini, Dan I. Lubman, Rachelle Buchbinder, Ting Xia, Suzanne Nielsen

Objectives To quantify factors associated with paramedic transport to hospital for older people in residential aged care facilities (RACFs) and supported accommodation, and to identify modifiable drivers of non-transport. Study Type Retrospective cohort study using routinely collected electronic patient care records, analysed with gradient boosting models and multivariable logistic regression. Setting Ambulance Tasmania attendances to RACFs and supported accommodation across Tasmania, 1January 2018 to 31 December 2024. Study Population All eligible ambulance attendances for people aged 65years or older at these facilities. Main Outcome Measures The primary outcome was transport to hospital. Scene time and clinical status at first assessment, summarised using the National Early Warning Score 2 (NEWS2) and Shock Index, were descriptive variables and candidate predictors. Results Of 23,317 attendances, 19,386 (83.1%) resulted in transport and 3931 (16.9%) did not. Most attendances were low risk. Crew skill set, calendar month, initial pain score, respiratory rate and NEWS2 category were the strongest predictors of transport. In adjusted logistic regression, extended care paramedic attendance was associated with markedly lower odds of transport than attendance by standard paramedic crews (adjusted odds ratio, 0.09 [95% CI, 0.07–0.12]), corresponding to an adjusted transport probability of 0.50 compared with 0.85 for intensive care paramedic crews, 0.86 for standard paramedic crews and 0.69 for other crews. Conclusions Paramedic transport decisions for RACF residents were strongly associated with acute illness severity, but crew skill set was also independently associated with transport. Attendances managed by extended care paramedics had lower adjusted probabilities of hospital transport. These findings suggest that extended-scope paramedic models warrant prospective evaluation in this setting.

Sharon Andrews, Pieter F. Fouche, Belinda Flanagan, Michael McDermott, Melanie Greenwood

Objective This study quantifies the short-term risk profiles of seven severe acute respiratory syndrome coronavirus 2 virus (SARS-CoV-2) vaccines—Comirnaty Bivalent BA.1, Comirnaty Bivalent BA.4-5, Comirnaty XBB.1.5, Spikevax Bivalent BA.1, Spikevax Bivalent BA.4-5, Spikevax XBB.1.5 and Nuvaxovid—administered as booster doses in Australia. Design This is a survey study using data collected from online surveys sent via AusVaxSafety, the Australian active vaccine safety surveillance system, 3days post-vaccination, soliciting reports of adverse events following vaccination. Participants and Setting Individuals 18years and older who received a SARS-CoV-2 vaccine booster at an AusVaxSafety vaccine surveillance site between 1 January 2023 and 31 August 2024. Main Outcome Measures Bayesian logistic regression was used to estimate risk of reported adverse events, seeking medical advice and impact on daily activities. Results Of 197,476 respondents, 59,089 (29.9%) reported at least one adverse event, of which the most commonly reported symptoms were injection site reaction (23.8% [46,988/197,476]) and fatigue (19.4% [38,352/197,476]). Symptom resolution was reported by 69.9% (41,299/59,089) by day 3 and 5.6% (11,006/197,476) reported any time lost from daily activities. The unadjusted proportion of respondents who sought medical advice was higher in those who received Spikevax XBB.1.5 (1.2% [212/17,551]) than the other vaccines (0.5% [379/69,493] to 0.7% [147/20,271]), but the modelled, adjusted mean risk of medical advice was similar (<2.5%) across subgroups for vaccine brands, co-administered vaccines, medical conditions, age, sex and Indigenous status. The modelled risk of any adverse event at age 40years ranged from 35.2% (95% credible interval [CrI], 32.2%–38.5%) for men who had received Comirnaty XBB.1.5 to 75.5% (95% CrI, 71.9%–78.8%) for women who had received Spikevax XBB.1.5. At age 80years, this risk was lowest across all vaccines, ranging from 12.0% (95% CrI, 11.2%–13.0%) for men who had received Comirnaty BA4-5 to 36.7% (95% CrI, 34.6%–38.7%) for women who had received Spikevax XBB.1.5. Conclusions The results of this study confirm the short-term safety and low impact on daily living of SARS-CoV-2 booster vaccine administration to Australian adults.

Evelyn Tay, Michael Dymock, Lucy Dawes, Lucy Deng, Thuy Nguyen, Alan Leeb, Julie A. Marsh, Nicholas Wood, Kristine Macartney, Thomas L. Snelling

Objective To quantify continuity of care in general practice in the Australian population, including variation according to patient characteristics and over time, to support ongoing policy reforms directed towards improving general practice care. Design and Setting Repeated cross-sectional analyses of linked whole-of-population data from the Medicare Benefits Schedule, the Medicare Consumer Directory and the Census of Population and Housing (2021). Participants Continuity was assessed in people with at least four general practitioner visits in a 2-year period (about 80% of the population). Main Outcome Measure Relational continuity of care in general practice, measured with the Usual Provider Index, for eight overlapping 2-year periods (2016–2017 to 2022–2023). High continuity was defined as having ≥70% of visits with one provider. Results About one-third of the population had high continuity of care (range: 31.3% in 2018–2019 to 37.2% in 2020–2021). After adjustment for age, sex and remoteness, high continuity was more common among those with greater care needs, including those who were older (≥70years vs. 0–14years: adjusted prevalence ratio [aPR], 1.88) or with health conditions (e.g., ≥3 vs. none: aPR, 1.14) and those who were living in more disadvantaged areas (e.g., most vs. least disadvantaged: aPR, 1.22), born overseas (e.g., born in Southern or Eastern Europe vs. born in Australia or New Zealand: aPR, 1.20) or not proficient in English (aPR, 1.29). However, it was less common for females compared with males (aPR, 0.90) and those living remotely (e.g., very remote vs. major cities: aPR, 0.43). Conclusion While most people in Australia do not receive continuous care in general practice with a specific provider, those with greater healthcare needs are more likely to. With ongoing policy reforms, monitoring continuity of care may provide insights into the consequences for quality of care.

Rosemary J. Korda

Objectives To examine the prevalence in Australia of stigmatising attitudes towards people with six different mental health conditions: depression, early and long-term/untreated forms of schizophrenia, bipolar disorder, borderline personality disorder and attention-deficit/hyperactivity disorder (ADHD). Design Cross-sectional population-based survey using the probability-based online panel Life in Australia. Participants responded to one of six vignettes describing a person with a mental health condition. Setting Australia, 11–25 November 2024. Participants Representative sample of 6032 adult residents of Australia. Main Outcome Measures Proportions of participants who agreed or strongly agreed with 13 stigmatising attitudes and proportions who were definitely or probably unwilling to interact in five different social situations with the person in the vignette. Results Stigmatising attitudes were generally lowest for depression and highest for long-term schizophrenia and borderline personality disorder. Beliefs about unpredictability had the highest endorsement: 61.9% (95% confidence interval [CI], 58.2%–65.5%) for long-term schizophrenia; 56.3% (95% CI, 52.5%–59.9%) for borderline personality disorder; 52.8% (95% CI, 49.0%–56.6%) for early schizophrenia; 50.7% (95% CI, 47.0%–54.4%) for bipolar disorder; 29.2% (95% CI, 25.9%–32.7%) for ADHD and 23.3% (95% CI, 20.2%–26.7%) for depression. Forcing treatment was endorsed by 25.9% (95% CI, 22.6%–29.5%) for early schizophrenia and 24.1% (95% CI, 21.0%–27.6%) for long-term schizophrenia. For all conditions, at least 20% of participants did not agree that the person in the vignette was a person of worth, with agreement ranging from 78.5% (95% CI, 75.1%–81.6%) for early schizophrenia to 67.4% (95% CI, 63.8%–70.9%) for long-term schizophrenia. There were high levels of unwillingness for the person in the vignette to marry into the family: ranging from 29.7% (95% CI, 26.4%–33.2%) for ADHD to 64.4% (95% CI, 60.7%–67.9%) for long-term schizophrenia. Conclusions Stigma related to mental health conditions remains prevalent in Australia and contributes to social and economic exclusion among those affected. Sustained action is needed across multiple sectors to address stigma, particularly towards conditions such as schizophrenia and borderline personality disorder, which are poorly understood within the community.

Amy J. Morgan, Anna M. Ross, Gayle McNaught, Rachel Green, Nicola J. Reavley

The 2025 NSW RSV Prevention Program, which achieved an estimated coverage of 63% maternal vaccination and 18% for infant immunisation, led to more than 40% reduction in RSV notifications and hospitalisations among infants aged younger than 6months.

Janaki Amin, Sally L. Ellis, Christopher Lambeth, Jessica Gugusheff, Christine Selvey