Volume 224, published ahead of Issue 10

We describe the first reported Buruli ulcer case likely acquired from a ringtail possum scratch, which represents a newly recognised mechanism for Buruli ulcer acquisition. We aim to alert health practitioners of this possibility in order to educate patients and facilitate early Buruli ulcer diagnosis, which reduces morbidity and allows less complex treatment. We also aim to influence public health messaging around the risk of Buruli ulcer acquisition from handling sick or injured possums.

Daniel P. O'Brien, Naomi Clarke, Sara Bonnici, Mohammad A. Hussain

We present a case of tetanus following a snakebite in Victoria, Australia. An otherwise healthy 58-year-old woman presented following suspected Tiger snake (Notechis scutatus) bite with envenomation. She was not up-to-date with tetanus vaccination and was not offered a booster vaccination. She re-presented 12 days later with features consistent with tetanus infection and was treated with tetanus immunoglobulin and metronidazole with clinical improvement. Snakebites remain a risk for tetanus infection and the assessment of tetanus risk should be included within clinical guidelines for Australian healthcare settings.

Adrian A. S. Doherty, Naomi N. E. Clarke, Sarah Fletcher, Sarah Huffam, Camille V. Awburn, Eugene Athan

Shift workers have temporal eating patterns characterised by irregular food intake and prolonged periods of eating with more energy intake occurring in night-time hours during night shifts. These patterns of eating against a backdrop of shift work exacerbate circadian misalignment, which impairs cardiometabolic profiles and increases the risk of developing overweight and obesity, diabetes and cardiovascular diseases. Limiting food intake at night and being mindful about food choices is beneficial on night shifts, but further research is required to determine appropriate timing and composition of food intake. Some food intake at night may be necessary in supporting individual alertness and performance at work and should be considered when recommending that shift workers minimise food intake at night. At the individual level, shift workers may benefit from minimising night-time food intake during night shifts. At the organisational level, healthy food consumption habits should be encouraged by improving access to healthy food at night, implementing scheduled meal breaks and providing information about healthy eating guidelines to employees. Medical professionals and Accredited Practising Dietitians (APD) should be aware of the impact of circadian misalignment on metabolic health and consider this when educating patients on adhering to healthy eating guidelines.

Yan Yin Phoi, Maxine P. Bonham, Jillian Dorrian, Michelle Rogers, Alison M. Coates

Objectives To examine the epidemiology of stroke and transient ischaemic attack (TIA), and quality of care provided to Aboriginal and Torres Strait Islander (‘Indigenous’) patients presenting to emergency medical services (EMSs) with stroke or TIA.DesignRetrospective population-based data linkage study.Setting, ParticipantsVictoria, Australia. Patients aged ≥ 18 years with hospital-confirmed stroke or TIA who presented to EMSs between 1 January 2015 and 30 June 2019 and were successfully linked with hospital or mortality datasets.Main Outcome MeasuresThirty- and 90-day mortality, crude and age-standardised incidence rates, EMS quality of care.ResultsAmong 32,163 patients, 287 (0.9%) were Indigenous. Indigenous patients were younger than non-Indigenous patients (median age, 62 vs. 77 years, p < 0.001). Age-standardised incidence of EMS attendance was higher within the Indigenous population (343 vs. 144 per 100,000 person-years; incidence rate ratio, 2.383 [95% confidence interval (CI), 2.084–2.711]). Rates of call-taker identification of stroke or TIA and hospital diagnoses were comparable; however, Indigenous patients were less likely to receive a stroke assessment from paramedics (166/285 [58.2%] vs. 21,271/31,605 [67.3%]; p = 0.001) and more frequently taken to stroke-capable hospitals (257/275 [93.5%] vs. 27,371/30,647 [89.3%]; p = 0.027), but less frequently taken to endovascular thrombectomy-capable hospitals (67/275 [24.4%] vs. 10,015/30,647 [32.7%]; p = 0.003). Adjusted mortality was similar between groups (30 days: hazard ratio, 0.814 [95% CI, 0.518–1.279]; 90 days: hazard ratio, 0.805 [95% CI, 0.534–1.214]). However, age-standardised incidence of 90-day mortality was higher within the Indigenous population (39 vs. 24 per 100,000 person-years; incidence rate ratio, 1.621 [95% CI, 1.031–2.398]). Indigenous patients also more often recontacted EMSs for any reason within 90 days (subdistribution hazard ratio, 1.548 [95% CI, 1.194–2.007]).ConclusionsThe age-standardised incidence of EMS attendance for stroke in the Indigenous population was more than double that for the non-Indigenous population. Although there was no difference in stroke identification at the time of the emergency call, Indigenous patients were less likely to be evaluated by paramedics for stroke.

Candice Menezes, Ziad Nehme, Luke J. Burchill, Tegwyn McManamny, Angela Dos Santos, Michelle Crilly, Luke P. Dawson, Benjamin Clissold, David Anderson, Emily Nehme

Objectives To analyse the extent and patterns of pharmaceutical industry funding of patient groups in Australia between 2013 and 2022, including the proportion of groups' income derived from industry payments in 2022.Study TypeLongitudinal observational study.Setting, ParticipantsAustralia, 1 January 2013–31 December 2022. Public disclosures of payments to patient groups from pharmaceutical companies who were members of Medicines Australia (the trade organisation for the prescription pharmaceutical industry in Australia) between 2013 and 2022 and from non-member companies with at least five registered prescription products in Australia.Main Outcome MeasuresValue (in Australian dollars) of reported payments to patient groups from the pharmaceutical industry and trends in payments by clinical area and over time. For patient groups that received industry funding in 2022, we also examined how this compared with their total income for that year.ResultsBetween 2013 and 2022, 45 pharmaceutical companies disclosed $95.7 million in funding to 390 patient groups. Funding was highly skewed, with 13 groups receiving 47.9% ($45,856,940/$95,724,493) of the total payments. The median funding over the decade was $34,374 (interquartile range [IQR], $8228–$122,898) per group. The total reported payments decreased by $293,246 (95% confidence interval, $125,489–$461,006) per year, but some clinical areas, such as oncology, saw an increase. For groups that received funding in 2022, the median proportion of income derived from industry was 2.2% (IQR, 0.3%–9.3%) and nine groups had over half their income from industry.ConclusionsIndustry funding of patient groups was widespread but skewed towards a small subset of groups and clinical areas. This may shift the focus of advocacy efforts towards certain conditions that align with current industry interests. Although further research is still needed on links between funding and patient group priorities, current disclosure measures may be insufficient to manage risks and access to other funding sources and additional safeguards may be needed to maintain independence.

Ashleigh Hooimeyer, Annim Mohammad, Alice Fabbri, Lisa Parker, Kellia Chiu, Barbara Mintzes

Objectives To estimate the direct medical costs of the Hep B Partnership Program (Hep B PAST) model of care compared with chronic hepatitis B (CHB) usual care from the health system perspective (Northern Territory (NT) Department of Health and the Commonwealth).Study TypeRetrospective cohort study (2014–2023) that linked primary care with inpatient, emergency, outpatient and outreach datasets. Costs were applied using National Weighted Activity Units, the Pharmaceutical Benefits Scheme and NT Government costings. A pre- and post-implementation design from a health system perspective was applied, with costs in 2023 Australian dollars.SettingRemote communities in the NT, Australia.ParticipantsThe cohort included all First Nations people living with CHB who were attending a clinic in a remote community that had consented to the Hep B PAST program, and who received care between 1 July 2014 and 31 May 2023.Main Outcome MeasuresAnnual mean and median healthcare costs per contact and per individual across service types, with comparisons of annual mean costs per individual between pre- and post-Hep B PAST using partially overlapping t-tests.ResultsAmong 1063 First Nations individuals with CHB, annual median costs per individual were similar for usual care ($639 [interquartile range, $366–1156]) and Hep B PAST ($770 [interquartile range, $400–1272]); mean costs were also similar for usual care versus Hep B PAST ($1701 vs. $1970; p = 0.12). By service type, annual median costs were similar for inpatient services ($7777 vs. $7795), primary care ($327 vs. $302) and outpatient visits ($1985 vs. $1858), and higher for Hep B PAST for emergency services ($1339 vs. $1672) and outreach care ($373 vs. $746).ConclusionsIn remote First Nations communities, Hep B PAST was delivered with a modest increase in direct medical costs compared with usual care. These findings can be used to inform future cost-effective evaluations. Future cost savings from decreased hepatocellular carcinoma and liver failure were not included.

Hoa Nguyen, Anh Le Tuan Nguyen, Paula Binks, Melita McKinnon, Emily Vintour-Cesar, Karen Wills, Nicola Stephens, Benjamin Cowie, Joshua S. Davis, Yuejen Zhao, Peter Nihill, Julie A. Campbell, Andrew J. Palmer, Jane Davies, Barbara de Graaff

Objective To identify barriers and facilitators to the timely detection and optimal management of chronic wet cough (CWC) in children from the perspective of health care providers (HCPs) across primary care clinics providing services to Australian Aboriginal people in multiple, diverse communities.Study TypeQualitative participatory action research study.Setting and ParticipantsEight Australian primary care clinics across three states and territories. Semi-structured interviews and focus groups were conducted with 83 HCPs from eight primary care clinics across metropolitan, regional and remote health service settings between May 2021 and July 2023.Main Outcome MeasuresBarriers to, and facilitators of, detection and optimal management of CWC in Aboriginal children in primary care settings.ResultsKey barriers identified included limited condition-specific knowledge, time constraints and competing priorities. HCPs identified key facilitators, such as the need for additional training, educational resources and various modifications to clinic systems. Barriers and facilitators were similar across settings. Proposed solutions varied and were based on several factors, such as community size, availability of existing infrastructure and local preferences. In addition, HCPs highlighted the importance of a culturally secure environment in fostering engagement and communication with Aboriginal families.ConclusionAlthough the barriers and facilitators to the detection and management of CWC in Aboriginal children were largely consistent across settings, solutions must be tailored to each community's unique circumstances. A comprehensive approach is required to overcome barriers and deliver the intervention within a culturally secure framework.

Gloria T. Y. Lau, Pamela Laird, Robyn Aitken, Melanie Barwick, Liam Bedford, Emily R. Bowden, Corey Dalton, Jamie Everingham, Angela Fuery, Reece Griffin, Neha Jain, Mina Kinghorn, Renae Knapp, Gabrielle B. McCallum, Peter Morris, Richard Norman, Peter C. Richmond, Aarti Saiganesh, Slade Sibosado, Maree Toombs, Roz Walker, Joan Wilson, Anne B. Chang, André Schultz

Objective To identify barriers and facilitators to the timely detection and optimal management of chronic wet cough (CWC) in children from the perspectives of carers, across multiple, diverse First Nations Australian communities.Study TypeQualitative participatory action research study.Setting and ParticipantsEight Australian communities across three states and territories. Semi-structured interviews and focus groups with 167 parents and carers of Aboriginal children were conducted between May 2021 and July 2023.Main Outcome MeasuresBarriers to and facilitators of detection and management of CWC in Aboriginal children in a primary care setting.ResultsKey barriers identified included inadequate health promotion, the common perception that CWC is normal and high turnover among health staff, leading to mistrust of newly onboarded health staff. The overarching facilitator identified was knowledge dissemination through health promotion, delivered in person by Aboriginal health staff using culturally secure resources, supplemented by posters placed in the community and the use of radio and social media. Individual communities expressed varied preferences regarding specific health promotion methods and designs. Communities valued staff who had spent considerable time within the community, allowing for the development of trust and rapport.ConclusionThe barriers and facilitators to detecting and managing CWC in children were generally consistent across the settings we studied. Implementation approaches to facilitate care require tailoring to local settings. Further, to reduce identified barriers for the detection and management of CWC in children, the incorrect perception that CWC is normal must be addressed and the potential harms of staff turnover need to be recognised.

Gloria T. Y. Lau, Pam Laird, Robyn Aitken, Melanie Barwick, Liam Bedford, Emily R. Bowden, Jamie Everingham, Angela Fuery, Reece Griffin, Neha Jain, Mina Kinghorn, Renae Knapp, Gabrielle B. McCallum, Peter Morris, Richard Norman, Peter C. Richmond, Aarti Saiganesh, Slade Sibosado, Cameron Taylor, Maree Toombs, Roz Walker, Joan Wilson, Anne B. Chang, André Schultz

Objective To co-design best practice principles (BPPs) for providing compassionate, holistic support to fathers and non-birthing parents exposed to perinatal trauma.DesignParticipatory action research methodology to generate qualitative data.Setting, ParticipantsFace-to-face workshops were conducted across the Greater Brisbane area and online workshops were held for national consultation from 23 April 2024 to 27 May 2025. Fathers and non-birthing parents with lived experience of perinatal trauma and a multidisciplinary team of health and community care professionals were included. Separate consumer (n = 11) and professional (n = 30) reference groups were established to authentically represent lived experience and professional perspectives on caring for birthing families. The co-designed BPPs were subsequently validated in National Workshops with consumers from diverse backgrounds (n = 74).ResultsThe co-design process generated 24 initial themes, which were iteratively consolidated by consensus into four BPPs: (1) compassionate and inclusive engagement; (2) policy and legislative reform; (3) education and learning opportunities; and (4) mental health screening and support for fathers and non-birthing parents. Accompanying practice and policy recommendations for each BPP were developed.ConclusionsFathers, non-birthing parents and healthcare and community care professionals co-designed a suite of BPPs to address gaps in perinatal healthcare following exposure to pregnancy and birth trauma. Fathers and non-birthing parents expressed a strong need to be formally recognised as stakeholders and recipients of perinatal healthcare services. The BPPs offer a co-designed framework for broader systemic reform and an actionable roadmap for equitable, trauma-informed and culturally responsive care for all parents, emphasising the need for further translational research and the national integration of inclusive perinatal healthcare services.

Alka Kothari, Dale Trevor, Glen Quinn, Jane Geltch, Joel Dulhunty, Helen Skouteris, Leonie K. Callaway

Objectives To identify evidence-informed drivers of sustainable systems change and actionable organisational priorities for advancing gender equality in medical leadership, aligned with national and international policy mandates, through the perspectives of key medical interest-holders.Study TypeCo-production implementation approach using mixed-methods, modified Delphi surveys and a Nominal Group Technique workshop. Reporting follows the REPRISE guideline for priority-setting of health research.Setting, ParticipantsFrom September 2021 to August 2023; online interviews, member survey, pre-workshop survey and a hybrid workshop with the Australian Medical Association (AMA). Purposive sample of AMA members, including doctors in training, doctors and medical leaders across all Australian states and territories.Main Outcome MeasuresConsensus-based priorities to inform a co-produced implementation plan for gender equality in medical leadership.ResultsSeventeen medical leaders were interviewed and 542 members completed the survey. Both consistently prioritised: (i) women's representation in leadership; (ii) inclusive and transparent recruitment; (iii) mentoring and networking; (iv) flexibility and family-friendly policies; and (v) gender targets and quotas. Triangulated findings identified eight internal and three external opportunity areas. A priority-setting workshop with 22 leaders generated 10 consensus priorities: five internal organisational (gender equity education; transparent leadership selection including gender targets; monitoring and reporting; promoting respect and monitoring behaviour at meetings/events; and leadership development for emerging women leaders) and five external (committed leadership for gender equity in medicine; advocacy for data and reporting; flexible career pathways; recognition of mentoring; and strategies to address the gender pay gap).ConclusionThrough a collaborative, evidence-informed process, we coproduced consensus-based priorities to advance gender equality in medical leadership with a leading national professional association that influences health policy. This structured approach is adaptable to other organisational contexts seeking to implement equity-focused interventions. The resulting priorities have directly informed an action plan and implementation strategy underway to promote gender equity within the association and across the broader medical profession.

Belinda Garth, Jenny Proimos, Thuy Vy Nguyen, Sally Cross, Sarah Whitelaw, Helena J. Teede

To the Editor, Thurtle's timely article [1] is one of a sea of examples where the default position of many of our healthcare bodies is captured very aptly by the Lancet article title: ‘Gaza has been failed by silence and impunity’ [2]. Both articles make for challenging reading, demonstrating how even pathways to publication have created their own form of denial and distance....

Ayman Hamdan, Anisa J. N. Jafar

To the Editor, We read with interest the review by Vaz and colleagues [1] examining metabolic dysfunction-associated steatotic liver disease (MASLD) in Australia. They should be commended on synthesising epidemiological data and emphasising fibrosis as the principal determinant of liver-related morbidity and mortality. Their focus on fibrosis risk stratification, using the Fibrosis-4 Index followed by vibration-controlled transient elastography or enhanced liver fibrosis testing, reflects international consensus and is pragmatic and scalable given rising disease prevalence [2]....

Yousef Hakimi, Prarthana Thiagarajan, Michael Braude

In Reply We thank Hakimi and colleagues [1] for their interest in our article summarising the epidemiological data pertaining to metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction-associated fatty liver disease (MAFLD) in Australia [2]. We agree with their sentiments that the multisystem nature of MASLD/MAFLD necessitates a broader approach to managing metabolic health and that it is imperative for governmental policy initiatives to curb the rising prevalence and associated morbidity and mortality that occur with metabolic-associated or obesity-related diseases, which currently place a strain on resource-limited public health services....

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