Volume 224, published ahead of Issue 8

Objective Determine whether watchful waiting is non-inferior to immediate oral antibiotics for uncomplicated acute otitis media among urban Aboriginal and Torres Strait Islander children.Study TypeNon-inferiority unblinded randomised controlled trial.Setting and ParticipantsEight Aboriginal Medical Services across three Australian states and territories between 25 August 2014 and 2 June 2023. Children (aged 1.5–16 years) with type B tympanograms and bulging tympanic membrane or acute pain/irritability were randomised by site and age (1.5–6 years and 7–16 years), with stratification using randomly allocated, permuted blocks of four and six in length.Main Outcome MeasuresWatchful waiting compared with immediate oral antibiotics using modified intention-to-treat (using only available data) and per-protocol analyses of Day 7 clinical resolution with non-inferiority threshold set at 10 percentage points.ResultsChildren were randomly allocated to watchful waiting (134), six of whom were lost to follow-up or immediate antibiotics (129) with three lost to follow-up. Resolution occurred in 57/106 (53.8%) watchful waiting and 68/113 (60.2%) immediate antibiotic group of those with complete Day 7 data (−6.4 percentage points difference; 90% confidence interval [CI], −17.4 to 4.6) (modified intention-to-treat analysis). Per-protocol analysis similarly demonstrated reduced resolution in the watchful waiting group (49/97; 50.5%) compared with immediate antibiotics (67/112; 59.8%) with −9.3 percentage points difference (90% CI, −20.6 to 2.0). There was less Day 3 diarrhoea in watchful waiting (3/90; 3.3%) than in the immediate antibiotic group (13/93 [14.0%]; −10.7 percentage points difference; 95% CI, −18.6 to −2.7) but no other differences in vomiting, diarrhoea or rash (Days 3–14). Day 7 analgesia use was higher in the watchful waiting (53/107 [49.5%]) than immediate antibiotic group (37/116 [31.9%]; 17.6 percentage points difference; 95% CI, 4.9 to 30.1). There were no intervention-related severe adverse events or perforations.ConclusionAlthough our results are numerically similar to those reported in other low-risk populations and no unexpected safety signals were observed in the watchful waiting arm, non-inferiority was not established. Larger, adequately powered trials are required to determine whether watchful waiting is non-inferior in this population.Trial RegistrationAustralian New Zealand Clinical Trials Registry ACTRN#12613001068752

Jennifer S. Reath, Hasantha Gunasekera, Sanja Lujic, Amanda J. Leach, Letitia Campbell, Robyn Walsh, Tim Usherwood, Geoffrey K. Spurling, Claudette A. Tyson, Deborah A. Askew, Kelvin Kong, Chelsea J. Watego, Peter Morris, Wendy Hu, Penelope A. Abbott

Objectives Develop a roadmap of contextualised strategies to support international medical graduates (IMGs) on the pathway into satisfying rural general practitioner careers in Australia.DesignRealist evaluation approach.Setting, ParticipantsOnline semi-structured interviews, focus groups and intermittent feedback cycles developed, refined and confirmed a contextualised roadmap of strategies between 1 November 2024 and 27 July 2025. Participants were purposefully selected for IMG background and different pathways into rural general practice careers across Australia. This included a 10-person project advisory group and 31 external participants covering decision-makers, training teams, supervisors and trainees. Questions explored practical strategies to drive comfort, confidence, competence, belonging and bonding.Main Outcome MeasuresContextualised strategies for IMGs to achieve satisfying rural general practice careers.ResultsThe roadmap identified that when migrating and acclimatising, providing IMGs with centralised resources and information on rural general practice training and careers promotes comfort and empowerment. When moving to new workplaces and communities, providing IMGs with supportive workplaces for early supervised practice, skill bridging and opportunities to connect with other doctors', families and communities stimulates IMG confidence, competence and sense of community belonging. When training to become a general practitioner rurally, providing IMGs with family-focused, equitable training matched to the IMG and the community, and training that builds on IMG capabilities, promotes a sense of professional belonging and bonding. We identified that early intervention and a continuity of supports are important for more comprehensively supported IMGs.ConclusionsOngoing timely support, when multi-layered, tailored and integrated, may assist IMGs to gain specialist general practice qualifications, feel valued and to settle in rural general practice roles. The roadmap provides a basis for planning coordinated longitudinal support by distributed agencies.

Belinda G. O'Sullivan, Kim J. Omond, Neysan Sedaghat

Objective To characterise the associations of heat and bushfire smoke with health services utilisation and medication use at a national scale to support Australia's first National Climate Risk Assessment.DesignCross-sectional, population study, covering health conditions with the highest burden of disease.Setting and ParticipantsPeople in Australia accessing public health services between 2014 and 2020 for care related to cardiovascular, respiratory and mental health conditions.Main Outcome MeasuresRelative risks of heat and bushfire smoke (particulate matter ≤ 2.5 μm in diameter [PM2.5]) on health system utilisation and medication use, measured as emergency department (ED) presentations, hospital inpatient admissions, Medicare Benefits Schedule service claims in primary care and Pharmaceutical Benefits Scheme prescriptions dispensed. Relative risks (RRs) and 95% confidence intervals were estimated for short-term lags between exposure periods and health system usage.ResultsHeat was most strongly associated with ED presentations, with a RR of 1.033 (95% CI, 1.023–1.043; p < 0.001) per degree temperature change for respiratory conditions and 1.023 (95% CI, 1.016–1.031; p < 0.001) for mental health conditions. PM2.5 at a 1-day lag had the highest association with hospital admissions, with a RR of 1.014 per 1 μg/m3 change in particulate density for both cardiovascular (p = 0.001) and respiratory (p = 0.002) conditions. Primary care visits for mental health conditions were strongly associated with levels of PM2.5 (RR, 1.049 [95% CI, 1.040–1.058]; p < 0.001) and with temperature (RR, 1.027 [95% CI, 1.014–1.039]; p < 0.001), while medication use increased across respiratory, cardiovascular and mental health categories in response to both exposures, with particulate matter showing stronger effects for cardiovascular, respiratory and mental health prescriptions. Mental health outcomes consistently showed vulnerability across all domains.ConclusionHeat was strongly associated with acute ED presentations, while particulate matter was strongly associated with hospital admissions and medication use. Mental health services are broadly sensitive to both exposures. These findings emphasise the need for integrated air quality management and heat-health polices to reduce system-wide health burdens.

Hwan-Jin Yoon, Justin Boyle, Ibrahima Diouf, Rajiv Jayasena

This is one of the first reported cases of storage mite anaphylaxis in Australia, occurring in an infant who had two episodes of severe anaphylaxis, triggered by previously tolerated foods. Both episodes occurred following extended periods of food storage, and in both instances, the child required two doses of intramuscular adrenaline. Skin prick testing was negative to implicated foods, but demonstrated sensitisation to house dust mite, and serum-specific IgE confirmed storage mite sensitisation. Clinician recognition of this condition is essential for timely diagnosis and implementation of preventive measures to reduce further episodes of life-threatening anaphylaxis in at-risk patients.

Eliza Kluckow, Katie Frith

Virginia Barbour

Michael J. Stewart, Tom R. Sutherland