Volume 224 Issue 8

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

Adult liver transplantation practice in Australia and New Zealand has changed substantially over the past decade in response to shifting liver disease epidemiology and advances in donor organ preservation. Alcohol-related liver disease and metabolic dysfunction-associated steatotic liver disease have become leading indications for adult liver transplantation in Australia and New Zealand. Transplant recipients are increasingly older and medically complex, necessitating multi-disciplinary assessment including evaluation of frailty. Indications for liver transplantation have expanded to include selected patients with severe alcohol-related hepatitis, acute-on-chronic liver failure, extended-criteria hepatocellular carcinoma and other highly selected non-resectable liver malignancies including colorectal liver metastases and cholangiocarcinoma. In parallel, donor utilisation has evolved, with increasing use of expanded-criteria donors and donation after circulatory determination of death. Machine perfusion technologies are increasingly used in Australia to optimise marginal liver grafts and minimise waitlist mortality. Having an awareness of these evolving indications, recipient complexity and donor optimisation strategies is essential to support timely liver transplantation referral, improve inter-disciplinary understanding, allow equitable access and provide appropriate stewardship of limited donor organs.

Fadak Mohammadi, Alan J. Wigg, Ken Liu, Simone I. Strasser

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 estimate population-level eligibility for glucagon-like peptide-1 receptor agonist (GLP-1RA) medications among adults in Australia, according to Therapeutic Goods Administration-approved indications for chronic weight management and secondary prevention of cardiovascular disease in individuals with overweight or obesity.Study TypeCross-sectional analysis of data from the Australian Bureau of Statistics 2022 National Health Survey.Setting, ParticipantsNon-pregnant adults aged ≥ 18 years who were residents of Australia living in a private dwelling.Main Outcome MeasuresTotal number of adults eligible for GLP-1RA medications according to approved indications for chronic weight management and secondary prevention of cardiovascular disease in individuals with overweight or obesity, across subgroups defined by body mass index, weight-related comorbidities and/or sociodemographic factors.ResultsOverall, 39.7% (95% confidence interval [CI], 38.4%–41.0%) of adults were eligible for GLP-1RA use for chronic weight management, accounting for 7.8 million (95% CI, 7.6–8.1 million) individuals. Among those eligible, 2.9 million (95% CI, 2.7–3.1 million) adults had no weight-related comorbidities, 3.3 million (95% CI, 3.1–3.4 million) adults had one weight-related comorbidity and 1.7 million (95% CI, 1.6–1.8 million) adults had at least two weight-related comorbidities. The proportion of adults eligible under this indication varied across clinical and sociodemographic factors. Among those eligible under the chronic weight management indication, up to 338.9 thousand (95% CI, 271.3–406.5 thousand) adults also met the indication criteria for secondary prevention of cardiovascular disease.ConclusionAbout 7.8 million Australian adults are eligible to access GLP-1RAs for chronic weight management, with up to 338.9 thousand adults also qualifying according to the indication for established cardiovascular disease. This study provides a valuable reference for policymakers to understand the number of adults in Australia who may access GLP-1RA medications based on approved indication criteria and under various coverage scenarios.

Jasmin Castrillon, Chris Schilling, Sharmala Thuraisingam, Michael W. Hii, Priya Sumithran, Peter F. Choong, Michelle M. Dowsey, Cade Shadbolt

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

Objectives Patients in regional and rural areas consistently experience poorer lung cancer survival rates compared with those in metropolitan centres, but the reasons remain unclear. This study examined survival differences in non-small cell lung cancer (NSCLC) across Victoria and identified key prognostic factors contributing to these differences.DesignRetrospective cohort study.Setting and ParticipantsNSCLC patients diagnosed between 1 July 2011 and 22 May 2023 identified from the Victorian Lung Cancer Registry (VLCR).Main Outcome MeasuresResidential address and treatment institution were classified using the Modified Monash Model (MMM): Modified Monash (MM) category 1 (MM1) as metropolitan, MM2 as regional and MM3–MM7 as rural/remote. Demographic, socio-economic and cancer-specific factors were analysed as potential predictors of all-cause mortality.ResultsAmong 13,548 patients, 4244 (31%) lived in regional or rural/remote areas. Compared with metropolitan patients, these groups had higher smoking prevalence (metropolitan, 2848/9304 [31%] vs. regional, 366/1083 [34%] vs. rural, 1148/3161 [37%]) and were more likely to be Australian-born (metropolitan, 4919/9304 [53%] vs. regional, 873/1083 [81%] vs. rural, 2603/3161 [82%]; p < 0.001). Comorbidity burden was similar across groups (median, 1; interquartile range, 0.0–1.0; p = 0.19). Socio-economic disadvantage was more marked in regional and rural patients (median Index of Relative Socio-Economic Advantage and Disadvantage [IRSAD] deciles: metropolitan, 8.0 vs. regional, 5.0 vs. rural, 3.0; p < 0.001), and average travel times to treatment were longer (metropolitan, 0.4 vs. regional, 1.9 vs. rural, 2.8 h, respectively). Patients treated at regional institutions had poorer survival (hazard ratio [HR], 1.27; 95% confidence interval [CI], 1.19–1.35; p < 0.001). This difference persisted after adjustment for age, stage, performance status, smoking and comorbidities (HR, 1.11; 95% CI, 1.04–1.18; p = 0.001).ConclusionsRegional, rural and remote patients with NSCLC face greater socio-economic disadvantage and travel burdens, and experience poorer survival even after accounting for clinical and demographic factors. These findings highlight enduring inequities in lung cancer care and emphasise the need for targeted interventions to strengthen access, treatment equity and outcomes for non-metropolitan populations.

Evangeline Samuel, Eldho Paul, Mike Lloyd, Sanuki Tissera, Craig Underhill, Sagun Parakh, Phillip Parente, Inger Olesen, Javier Torres, Katharine See, Gavin M. Wright, David Langton, Thomas John, Matthew Conron, James Bartlett, Nicola Atkin, Nikolajs Zeps, Susan V. Harden, Wasek Faisal, John R. Zalcberg, Rob G. Stirling

Objective To leverage the Treatment of Recurrent and Advanced Colorectal Cancer (TRACC) registry (an Australian cancer database) to explore the ideal timing and sequence of therapies and the factors influencing these decisions in colorectal cancer (CRC) patients with liver-only metastases to inform contemporary decision-making and future trials.Study TypeRetrospective registry-based cohort study using the TRACC registry.Setting and ParticipantsConsecutive patients with liver-only metastatic CRC enrolled in the TRACC registry.Main Outcome MeasuresTo explore cancer biology, intended treatment at presentation, actual treatment received and the resultant outcomes for early-onset CRC (EOCRC) (≤ 50 years) and late-onset CRC (LOCRC) (> 50 years) patients with liver-only metastases from a real-world perspective.ResultsBetween 14 January 2009 and 2 September 2024, 1691 patients with liver-only metastatic CRC were enrolled in TRACC. These included 276 EOCRC patients (16.3%) and 1415 LOCRC patients (83.7%). In the EOCRC subset, there were more females (48.2% vs. 34.5%, p < 0.001), less comorbidity (Charlson comorbidity index score 0, 90% vs. 59%, p < 0.001), more left-sided primaries (76.1% vs. 65.7%, p < 0.001), more synchronous disease (53.3% vs. 42.1%, p < 0.001) and BRAF V600E mutations (13.9% vs. 8.1%; p = 0.010). Overall, EOCRC patients had a longer median survival compared with LOCRC patients (3.20 vs. 2.38 years, p < 0.001). For the 662 patients (39.1%) undergoing liver resection, median survival was 5.99 years in EOCRC patients and 5.88 years in LOCRC patients. For all patients and for those undergoing resection, respectively, B-Raf proto-oncogene, serine/threonine kinase (BRAF) (hazard ratio, 1.97 [p < 0.001] and hazard ratio, 2.25 [p < 0.001]) and Kirsten rat sarcoma viral oncogene homologue (KRAS) mutations were associated with worse outcomes (hazard ratio, 1.29 [p < 0.001] and hazard ratio, 1.34 [p = 0.003]).ConclusionDifferences in sex distribution, BRAF mutation rates, primary tumour site and overall survival suggest biological differences between EOCRC and LOCRC. Liver resection was associated with improved survival in LOCRC, with the benefits of all therapies varying depending on age, primary tumour site and whether patients presented with synchronous or metachronous liver-only metastases.

Savio G. Barreto, Christos S. Karapetis, Shahid Ullah, Matthew Burge, Susan Caird, Angus Campbell, Azim Jalali, Ross Jennens, Muhammad A. Khattak, Belinda Lee, Stephanie H. Lim, Shehara Mendis, Louise Nott, Timothy J. Price, Jeremy D. Shapiro, Jeanne Tie, Javier Torres, Colin Williams, Rachel Wong, Vanessa Wong, Peter Gibbs

Objectives Hypertensive disorders of pregnancy (HDP) are a leading reason for medically indicated preterm birth (PTB), yet their contribution to population-level PTB trends is poorly understood. We examined temporal trends in PTB overall and HDP-associated PTB in Victoria over an 11-year period spanning the COVID-19 pandemic, and distinguished changes in HDP prevalence from changes in preterm delivery among affected pregnancies.Study TypePopulation-based interrupted time-series study using seasonal autoregressive integrated moving average (SARIMA) models, with July 2018 (launch of a national preterm birth prevention program) pre-specified as a temporal reference point.SettingAll hospitals in Victoria, Australia.Participants779,325 singleton births at ≥ 20 weeks' gestation between 1 January 2012 and 31 March 2022.Main Outcome MeasuresMonthly rates (per 1000 singleton births) of overall PTB, HDP and HDP-associated PTB. Decomposition analyses separated changes in HDP prevalence from changes in preterm delivery among affected pregnancies.ResultsOverall PTB was lower after July 2018 (5.8%–5.6%), while HDP prevalence increased (6.4%–7.0%). HDP-associated PTB increased before mid-2018 (+0.75 per 1000 births per month; 95% confidence interval [CI], 0.50–1.00) but declined thereafter (−1.12 per 1000 births per month; 95% CI, −1.88 to −0.36). This reversal was driven predominantly by reduced iatrogenic PTB with HDP; spontaneous PTB with HDP showed no significant change. Despite rising HDP prevalence, decomposition analyses estimated 89 fewer HDP-associated PTB cases than expected under pre-2018 patterns, reflecting a decline in the proportion of HDP pregnancies delivered preterm. PTB without HDP showed no significant temporal change.ConclusionPTB among HDP-complicated pregnancies declined despite increasing HDP prevalence, consistent with a shift towards later gestational age at delivery rather than reduced disease incidence. These findings may reflect improvements in care and demonstrate that reductions in iatrogenic PTB are achievable even as major risk factors become more prevalent.

Melvin Marzan, Heng Jiang, Daniel Lorber Rolnik, Joanne M. Said, Lisa Hui

Bashi Kumar-Hazard, Andrew M. Bisits, Sharon L. Settecasse, Jenny Gamble, Hazel Keedle, Hannah G. Dahlen

Wendy Pollock, Alissa Fleming, Ensieh Fooladi, Joy Kloester, Anne Tremayne, Yasmin Zisin, Bethany Carr, Kym Davey, Suzanne Willey, Jenny Gamble

Liz Sutton, Harsha Ananthram, Rebecca Matthews

Michael J. Stewart, Tom R. Sutherland

Virginia Barbour