Volume 224 Issue 9

I collapsed at the gym when a massive pulmonary embolism caused my heart to stop. Unbelievably I survived thanks to a clinical trial delivering an extracorporeal membrane oxygenation (ECMO) heart–lung bypass machine directly to me at the gym. Hopefully out-of-hospital ECMO becomes an accepted emergency strategy to save more lives.

Hugh N. Burrill

Intranasal adrenaline has recently become available in Australia as a needle-free alternative to adrenaline autoinjectors for anaphylaxis management. Intranasal adrenaline may be particularly suitable for patients with barriers to adrenaline autoinjector usage, such as needle aversion or poor compliance with autoinjector carriage. However, although the data supporting real-world efficacy of intranasal adrenaline for anaphylaxis are growing, there is no published evidence confirming its efficacy in insect venom anaphylaxis. We report three cases of intranasal adrenaline (neffy, CSL Seqirus, Victoria, Australia) used to treat insect venom-induced anaphylaxis. Clinicians should be aware of the availability and current level of evidence for intranasal adrenaline for anaphylaxis management.

Thomas J. Young, Wilhelmina R. F. Johnson, Braydon L. Pennington, Troy Wanandy, Wun Y. Lau, Thanh-Thao A. Le

We describe two patients in Far North Queensland with acute Q fever. One patient had their infection complicated by a splenic abscess, the other developed a hepatic abscess. Both patients had contact with small Australian marsupials in the weeks before presentation and both required prolonged doxycycline to treat their infection.

Samantha J. Laws, Enzo Binotto, James Stewart, Jennifer Ho, Trent Yarwood, Josh Hanson, Simon Smith

Introduction This article summarises the recently published ‘Australian and New Zealand Journal of Psychiatry (ANZJP) Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Guidelines for the Management of Schizophrenia in Australia and Aotearoa New Zealand’ (https://journals.sagepub.com/doi/10.1177/00048674251406058).MethodsWe used the GRADE approach to evaluate the certainty of existing evidence and the strength of the recommendation was determined by the panel. The Guidelines are organised into seven sections: (1) physical health assessment; (2) pharmacological treatment; (3) psychological and psychosocial interventions; (4) family, whānau and carer involvement; (5) psychiatric comorbidities; (6) physical health and lifestyle interventions; and (7) special populations.Main RecommendationsA comprehensive yet tailored clinical assessment should be undertaken to identify treatable physical health comorbidities early, particularly for people with early psychosis.Pharmacotherapy should aim for the lowest effective dose with a tolerable and manageable adverse-effect profile (e.g., first-line pharmacotherapy with aripiprazole, brexpiprazole, cariprazine or lurasidone).Lifestyle interventions, particularly physical activity and multimodal lifestyle programmes, should be routinely offered to people with schizophrenia.Psychological and psychosocial interventions are essential components of care for people with schizophrenia, especially during the maintenance phase of illness.Clinicians should actively involve people with schizophrenia and their family, whānau and carers in shared decision-making.Comorbid psychiatric symptoms and conditions should be assessed and managed according to standard treatment approaches until more robust evidence base specific to schizophrenia becomes available.Changes in Assessment and Management as a Result of the GuidelinesThe ANZJP GRADE Guidelines synthesise the current evidence base across key domains relevant to the management of people with schizophrenia, offering practical recommendations that can be implemented in both clinical and systemic contexts. General practitioners have a pivotal role, especially in supporting the physical health and overall wellbeing of people with schizophrenia and assisting them to navigate complex healthcare pathways.

Shuichi Suetani, Frances Dark, Susanna Every-Palmer, Cherrie Galletly, Brian O'Donoghue, Sean Halstead, Dolores Keating, Steve Kisely, Nicole Korman, Julia Lappin, Sharon Lawn, Andrew Thompson, Nicola Warren, Dan J. Siskind

Introduction The Living Evidence for Australian Pregnancy and Postnatal Care (LEAPP) program was established in 2023 to update and transition the Australian Pregnancy Care Guidelines into living guidelines and to establish new, living Australian Postnatal Care Guidelines. The program is a collaboration of the Australian Living Evidence Collaboration (ALEC), the Australian College of Midwives, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists and 23 other Australian health organisations. The guidelines are developed using methods designed to meet the National Health and Medical Research Council standards. Clinical questions are prioritised by clinician and lived experience input. For each prioritised question, evidence is reviewed using systematic methods (existing published reviews or conducted de novo), contextual factors such as feasibility and equity are considered and new or updated recommendations are drafted. A lived experience panel and multidisciplinary clinical panels review draft recommendations. Unanimous endorsement by all 25 partner organisations is required before publication. Surveillance searches are conducted for most topic areas every 6 months. New and updated content is progressively added to the published guidelines.RecommendationsAs of August 2026 (version 11), the Australian Pregnancy Care Guidelines include 277 recommendations on more than 80 topics; 229 are new or updated since 2023. The new Australian Postnatal Care Guidelines include 149 recommendations on more than 20 topics. The guidelines are published online at https://livingevidence.org.au/living-guidelines/leapp/.Changes in Management as a Result of the GuidelineNew or updated recommendations include continuity of care, assessment and support on vaping, increased testing for syphilis, reduced testing for proteinuria, guidance on progesterone and cervical cerclage to prevent preterm birth, bereavement support, assessment and support for psychological birth trauma, screening for family violence, side sleeping in later pregnancy and a recommendation against vitamin D.

Miranda S. Cumpston, Anneliese Arno, Shaira N. Baptista, Shannon Barnes, Zoe Bradfield, Samantha P. Chakraborty, Caroline S. E. Homer, Stefan C. Kane, Nisha Khot, Steve McDonald, Steven McGloughlin, Tanya Millard, Jeremy J. N. Oats, Loyal Pattuwage, Matthew Quigley, Abdulbasit Seid, Rachel Silk, Alecia Staines, Anneliese Synnot, Alison Teate, Heath White, Tari Turner,

Objective To identify factors contributing to the known increased age-standardised incidence and mortality rates for lung cancer for Aboriginal and Torres Strait Islander people in Victoria, Australia.Study TypeRetrospective, population-based, case–control study using Victorian Cancer Registry (VCR) data and linked health administrative datasets.Setting and ParticipantsSelf-identified Aboriginal and Torres Strait Islander people (respectfully referred to hereon as Aboriginal) and non-Aboriginal people (aged > 18 years) diagnosed with lung cancer from 1 January 2008 to 31 December 2022.Main Outcome MeasuresClinical, pathological, demographic, socio-economic factors and biomarkers (programmed cell death-ligand 1 [PD-L1], anaplastic lymphoma kinase [ALK] and c-ros oncogene [ROS1]) were assessed. Endpoints were all-cause and lung cancer-specific mortality. Survival analyses were conducted using Cox regression.ResultsAboriginal people (N = 512) were younger (p < 0.001), more likely to live outside a major city (p < 0.001) and in areas of greatest disadvantage (p < 0.001) than non-Aboriginal people (N = 43,468). More Aboriginal females had small cell lung cancer compared with non-Aboriginal females (17% vs. 10%), more Aboriginal males had adenocarcinomas (41% vs. 36%) and squamous cell carcinomas (26% vs. 20%), compared with non-Aboriginal males. There were no differences in the proportions of PD-L1-positive disease nor ALK or ROS1 gene rearrangements. A higher risk of all-cause mortality (hazard ratio, 1.12; 95% CI, 1.01–1.24; p = 0.03) for Aboriginal people after stratification for age, sex and lung cancer subtype was identified.ConclusionThis study identified that Aboriginal people were younger, more likely to be living outside of major cities and in areas of greatest inequity than non-Aboriginal people, which is an ongoing manifestation of colonisation. Aboriginal people diagnosed with lung cancer had an increased all-cause mortality compared with non-Aboriginal people.

Alice R. T. Bergin, Luc te Marvelde, Roger L. Milne, Benjamin J. Solomon, Kris Ivanova, Peter Savas, Stephen J. Luen, Jay Hamann, Andrea Casey, Nicole Watt, Sue M. Evans, Gail Garvey, Sherene Loi

Objectives To quantify cardiovascular disease (CVD) risk, and implications for targeting preventive pharmacotherapy, using the 2023 guideline-recommended Australian CVD risk algorithm, and compare this to the previous (2012) algorithm.Study TypeApplication and comparison of two risk prediction algorithms.Setting and ParticipantsData from 115,873 people aged 45–74 years without existing CVD, who had a clinical encounter between September 2020 and August 2022, recorded within MedicineInsight, a longitudinal primary care database covering 8% of Australian general practices.Main Outcome MeasuresCVD risk distribution and risk categorisation into low-, intermediate- and high-risk groups under the 2023 and 2012 algorithms. Cohen's kappa and Bland–Altman plots were used to assess agreement and concordance.ResultsUsing the 2023 CVD risk algorithm and revised thresholds, 9.7% of participants were at high CVD risk (≥ 10% 5-year risk or clinically determined high risk); 26.4% were at intermediate CVD risk (5% to < 10% 5-year risk) and 63.9% were at low CVD risk (< 5% 5-year risk). Corresponding 2012 figures for CVD risk were 17.6% high (> 15% 5-year risk or clinically determined high risk), 11.6% intermediate (10%–15% 5-year risk) and 70.8% low (< 10% 5-year risk). Differences in proportions at high risk were largely driven by changes to clinically determined criteria for high risk. Overall, there was moderate-to-substantial agreement (linear-weighted kappa = 0.62) and concordance (Kendall's tau-b = 0.74) between algorithms.ConclusionProportions estimated at low risk and not routinely recommended pharmacotherapy align with international standards and were similar between guidelines. Although fewer people would be recommended pharmacotherapy due to being high risk under the updated versus previous guidelines, this likely reflects more accurate updated CVD risk estimation for the contemporary Australian population. The 2023 guidelines include a discretionary step (untested in our study) allowing adjustment based on additional factors. To ensure continued reduction of CVD burden across the population, we emphasise the use of this reclassification step by clinicians and consideration of the benefits of pharmacotherapy for those at intermediate risk.

Nina Lazarevic, Meghana Bhat, Grace Joshy, Danielle C. Butler, Mark Woodward, Anushka Patel, Rod T. Jackson, Garry Jennings, Rosemary Wyber, Ellie Paige, Emily Banks

Objectives Long-term and chronic health conditions are associated with a significant burden of disease and economic impact in Australia. Although improving health outcomes requires a multifactorial approach, up-to-date clinical guidelines can optimise healthcare delivery by providing clinicians with evidence-based, actionable recommendations. We aimed to determine the currency and key methodological characteristics of national clinical guidelines published in Australia and focussed on areas of highest prevalence and burden of disease.Study Design and SettingWe conducted a cross-sectional analysis by searching PubMed, the Guidelines International Network International Guidelines Library and Australian college and society websites in July 2025 for national clinical guidelines in the five areas of highest prevalence and burden of disease, as defined by the Australian Bureau of Statistics and Australian Institute of Health and Welfare, respectively. Information and metrics relating to time since publication, time since last evidence search and methods and processes (e.g., reporting of clinical questions and Population, Intervention, Comparison, Outcome [PICO] criteria and approval of the guideline by the National Health and Medical Research Council [NHMRC]) were tabulated and analysed.ResultsThirty-one guidelines published between 2002 and 2025 were identified, with most relating to diabetes or mental health. The mean times since publication and last search date were 8.6 and 9.8 years, respectively. Most provided details regarding clinical questions (77%), PICO criteria (61%), search strategies (68%) and other methodological considerations, however, fewer than half used Grading of Recommendations Assessment, Development and Evaluation (GRADE) to assess certainty of evidence or provided details regarding conflicts of interest (48% each). Of the 18 guidelines approved by the NHMRC, five were developed within the previous 5 years and remain approved.ConclusionFor most high-priority clinical conditions in Australia, there are no up-to-date evidence-based guidelines available to support clinical decision-making. Guideline developers and funders should invest more energy and resources into planning for updates and ensuring that methods and processes are optimised to facilitate this, such as considering a living approach.

Heath White, Ethan Fernandes, Kristina Peduru-Arachchige, Tari Turner, Steven McGloughlin, Steve McDonald

Objectives To characterise osteoporosis medicine prescribing patterns following low-trauma fractures and identify predictors of early treatment initiation.Study TypeRetrospective population-based cohort study.SettingNew South Wales, Australia, using statewide linked administrative health data.ParticipantsAdults aged ≥ 50 years with an incident low-trauma fracture between January 2011 and June 2019.Main Outcome MeasuresPrimary outcomes were osteoporosis treatment prescribing patterns and timing of initiation after incident fracture over 3 years, categorised as early (within 12 months), late (within 1–3 years) or no initiation. Secondary analyses examined predictors of time to treatment initiation within 12 months using Fine–Gray competing-risk regression.ResultsAmong 132,268 individuals with incident fractures, 63.7% (84,222) were female. Overall, 29,802 (22.5%) initiated osteoporosis medicine, whereas 102,466 (77.5%) remained untreated. Among females (mean [standard deviation] age, 77.7 [10.1] years), 20.1% initiated therapy within 12 months, 7.0% within 1–3 years, and 72.9% remained untreated. Among males (mean [standard deviation] age, 77.2 [10.0] years), the corresponding proportions were 10.8%, 3.7% and 85.6%. After accounting for the competing risk of death, treatment initiation was more likely with non-distal fractures, older age, polypharmacy, prior steroid use, prior dual-energy x-ray absorptiometry and later fracture year, and less likely with greater comorbidity, rural or regional residence and prior hospitalisation for falls. The strongest associations were for hip or vertebral fracture (subdistribution hazard ratio range, 1.90–3.03) and high comorbidity burden (subdistribution hazard ratio range, 0.72–0.75). Almost one in four late initiators had a refracture before starting treatment. Denosumab rapidly replaced oral bisphosphonates as the dominant therapy over time.ConclusionMore than three-quarters of individuals remain untreated after fracture, highlighting persistent and substantial gaps in secondary fracture prevention. Treatment initiation is strongly associated with fracture site and multimorbidity burden, and initiation rates are lower in males. Increasing reliance on denosumab underscores the need for careful long-term treatment planning and strategies.

Mike Lin, Huy Nguyen, Thach Tran, Robert D. Blank, Dana Bliuc, Jacqueline R. Center

Objectives Climate change, associated with heat spikes, floods, wildfires and changing patterns of vector-borne diseases, is a major determinant of health, and health system functioning. Understanding public perceptions of climate-related health risks and system preparedness can support equitable policy responses and effective health messaging.Study TypeCross-sectional.SettingOnline survey from 20 June to 27 August 2025.Participants6030 adults, aged ≥ 18 years, broadly representative of the Australian population.Main Outcome MeasuresThe AUstralian-CLimate and Health Attitudes, RIsk and Trust in the sYstem (AU-CLARITY) survey collected data on demographics, health status, experiences of climate-related events, and views on climate change and health system preparedness.ResultsRespondents (65%, 3910/6030) were concerned about climate change, yet only 45% (2735/6030) perceived it as a serious risk to their own health. Personal risk perception declined with age (odds ratio [OR] = 0.98; 95% confidence interval [CI], 0.98–0.98) and was higher among females (OR = 1.28; 95% CI, 1.15–1.43), First Nations people (OR = 1.44; 95% CI, 1.22–1.71), multilingual individuals (OR = 1.44; 95% CI, 1.22–1.71) and those with higher education (OR = 1.28; 95% CI, 1.12–1.46). Personal experience of a climate-related event increased perceived risk (OR = 1.97; 95% CI, 1.73–2.24). Regional and remote residents were less likely to perceive health risk (OR = 0.76; 95% CI, 0.65–0.89). A third (37%; 2209/6030) of respondents believed that the healthcare system was prepared for climate change. Being female (OR = 2.35; 95% CI, 2.10–2.65), having a chronic condition (OR = 1.47; 95% CI, 1.28–1.68) and older age (OR = 1.01; 95% CI, 1.01–1.01) increased perceptions that the system was unprepared. Those with higher education, who had been personally impacted, or identified as First Nations had more confidence in the system's preparedness.ConclusionsMany Australians recognise climate change as a health challenge; personal risk perception and confidence in system preparedness vary. Targeted health policies are needed to effectively communicate health risks and support healthcare's climate change resilience.

Jeffrey Braithwaite, Carolynn L. Smith, Yvonne A. Zurynski, Louise A. Ellis, Georgia Fisher, Kate Churruca, Lisa Pagano, Samantha Spanos, Janet C. Long, Christina Rojas, S. Bruce Dowton

Objective To examine short-term safety outcomes following vaccination at 2-, 4-, 6- and 12-month timepoints, comparing infants receiving meningococcal B (MenB) vaccines concomitantly with National Immunisation Program (NIP) vaccines to those receiving vaccines at separate visits.Study TypeObservational cohort survey study.Setting, ParticipantsOnline surveys via AusVaxSafety were sent 3 days post-immunisation to collect reports of adverse events following immunisation (AEFIs). Infants aged < 15 months were included if, between 1 April 2022 and 31 March 2025, they received NIP and MenB vaccines concomitantly or separately at schedule timepoints, and their carer completed an AusVaxSafety survey.Main Outcome MeasuresBayesian multinomial logistic regression estimated the risk of reporting any AEFI, medical review and impact on daily activities following each vaccination strategy.ResultsOf 45,215 infants receiving NIP and MenB vaccines at the 2-, 4-, 6- and 12-month timepoints (with or without other vaccines), 72% (32,751/45,215) received concomitant vaccination. Excluding those with additional vaccines, 10,959 were included in the analysis. The adjusted model showed the cumulative risk of any AEFI was lower under the concomitant strategy compared with the separate strategy at 2 months (29% [95% credible interval (CrI), 26% to 31%] vs. 35% [95% CrI, 31% to 40%], risk difference −6.7 [95% CrI, −11.5 to −2.2]) and similar at 4 months (45% [95% CrI, 43% to 48%] vs. 47% [95% CrI, 43% to 52%]), 6 months (45% [95% CrI, 42% to 49%] vs. 44% [95% CrI, 38% to 50%]) and 12 months (47% [95% CrI, 45% to 50%] vs. 52% [95% CrI, 48% to 56%]). Medical review within 3 days was lower at 12 months in the concomitant group (4.1% [95% CrI, 3.4% to 5.0%] vs. separate 6.3% [95% CrI, 4.7% to 8.3%], risk difference −2.2 [−4.3 to −0.4]) and comparable across earlier time points (concomitant 2.3%–4.2% vs. separate 3.6%–3.9%). Impact on daily activities was low (concomitant 1.1%–8.5% vs. separate 1.6%–8.3%) with no differences observed between strategies.ConclusionsSeparating MenB vaccines from routine NIP vaccines does not reduce, and may increase, the cumulative reaction burden across visits. Findings support concomitant administration.

Thuy Nguyen, Evelyn C. S. Tay, Michael Dymock, Thomas L. Snelling, Lucy Dawes, Julie Marsh, Yue Wu, Alan Leeb, Nicholas Wood, Lucy Deng

This study identified and characterised 1207 emergency department presentations related to gabapentinoid overdose in Victoria from 2009–2010 to 2023–2024. Presentation rates increased substantially since 2009–2010, and about half (49.5%; 597/1207) of all presentations were classified as intentional. Co-ingestants were common, although 36.2% (437/1207) of presentations were reported to involve gabapentinoids alone.

Bishaal Tej Gurung, Amy McNeilage, Angus Skeen, Tina Lam, Joanna F. Dipnall, Jane Hayman, Suzanne Nielsen, Ting Xia

This study evaluated Australia's national respiratory syncytial virus (RSV) burden and highlighted key data gaps. Hospitalisations (2016–2019) peaked in infants aged < 3 months (4014/100,000) and adults aged ≥ 65 years (122/100,000), nearly doubling over the period. Unspecified causes comprised ≈55% of bronchiolitis hospitalisations in children aged < 24 months. Laboratory notifications (2023) peaked at 6–11 months (7778/100,000). Real-time data integration addressing case-ascertainment and diagnostic testing frequency is essential for accurate burden estimates and future immunisation strategies.

Chisato Imai-Boulter, Jean Li-Kim-Moy, Clayton Chiu, Sanjay Jayasinghe, Kristine Macartney

To the Editor, I read with interest the perspective by Aitken and colleagues on the role of medical colleges in ensuring participation in Clinical Quality Registries [1]. The authors should be commended for discussing this issue and for calling for stronger accountability. Although they highlighted the importance of clinical audit, the reality is that, despite long-standing guidelines from the Royal Australasian College of Surgeons (RACS) and state health departments [2, 3], clinical audit is performed inconsistently and often poorly. Morbidity and mortality meetings, although universally endorsed, vary widely in quality and many fail to deliver genuine quality improvement. High-quality, effective clinical audit meetings (surgical mortality and morbidity meetings) are rare, notwithstanding RACS guidelines or the administrative box-ticking exercises often done by clinical governance departments [4]....

Thomas J. Hugh

In Reply: We thank Hugh for his comments [1] on our article [2] and the opportunity to reply.The monthly morbidity and mortality meetings have been central to surgical quality since the founding of the American College of Surgeons in 1913. However, as Hugh notes, their quality is highly variable and their conclusions not robustly reported. Further, many are inwardly focused and do not assess care against external evidence-based or peer benchmarks....

Robert J. Aitken, Julian A. Smith, Guy J. Maddern

To the Editor, We thank Kazi and colleagues for their recent publication outlining important outcomes concerning sex differences in people from New South Wales with ST-elevation myocardial infarction (STEMI) [1]. We agree with the authors that efforts must be made to address inequities in myocardial infarction treatment and outcomes worldwide with respect to sex [2]....

Adam C. Livori, Jedidiah I. Morton, Dianna J. Magliano, Jonathan E. Shaw

In Reply: The aim of our article was to examine whether sex differences in care and outcomes for people with ST-elevation myocardial infarction (STEMI) had declined through analysis of the New South Wales Admitted Patient Data Collection from 2011 to 2020 [1]. This found that care and outcomes had improved over time among patients with STEMI and that this improvement was steeper in females compared with males and, thus, the gap by sex had narrowed over time....

Samia Kazi, Simone Marschner, Clara K. Chow