Systematic review

Financial and structural support is needed for the geographic decentralisation of medical abortion training and services

Greta Skahill · Mridula Shankar

Few interventions for Aboriginal and Torres Strait Islander people with type 2 diabetes have been reported in peer-reviewed publications

Ciying Tan · Zoe Williams · Mohammad Ashraful Islam · Ray Kelly · Tuguy Esgin · Elif I Ekinci

Quality research into the impact of physical activity interventions on type 2 diabetes in Indigenous people is sparse

Raymond J Kelly · Rona Macniven · Leonid Churilov · Margaret J Morris · David O'Neal · Elif I Ekinci

The sensitivity of RATs used for self-testing was lower than reported by manufacturers, increasing the risk of false negative results

Katy JL Bell · Yuyang Li · Ellie Medcalf · Deonna Ackermann

Objective: To review and synthesise the global evidence regarding the health effects of electronic cigarettes (e‐cigarettes, vapes). Study design: Umbrella review (based on major independent reviews, including the 2018 United States National Academies of Sciences, Engineering, and Medicine [NASEM] report) and top‐up systematic review of published, peer‐reviewed studies in humans examining the relationship of e‐cigarette use to health outcomes published since the NASEM report. Data sources: Umbrella review: eight major independent reviews published 2017–2021. Systematic review: PubMed, MEDLINE, Scopus, Web of Science, the Cochrane Library, and PsycINFO (articles published July 2017 – July 2020 and not included in NASEM review). Data synthesis: Four hundred eligible publications were included in our synthesis: 112 from the NASEM review, 189 from our top‐up review search, and 99 further publications cited by other reviews. There is conclusive evidence linking e‐cigarette use with poisoning, immediate inhalation toxicity (including seizures), and e‐cigarette or vaping product use‐associated lung injury (EVALI; largely but not exclusively for e‐liquids containing tetrahydrocannabinol and vitamin E acetate), as well as for malfunctioning devices causing injuries and burns. Environmental effects include waste, fires, and generation of indoor airborne particulate matter (substantial to conclusive evidence). There is substantial evidence that nicotine e‐cigarettes can cause dependence or addiction in non‐smokers, and strong evidence that young non‐smokers who use e‐cigarettes are more likely than non‐users to initiate smoking and to become regular smokers. There is limited evidence that freebase nicotine e‐cigarettes used with clinical support are efficacious aids for smoking cessation. Evidence regarding effects on other clinical outcomes, including cardiovascular disease, cancer, development, and mental and reproductive health, is insufficient or unavailable. Conclusion: E‐cigarettes can be harmful to health, particularly for non‐smokers and children, adolescents, and young adults. Their effects on many important health outcomes are uncertain. E‐cigarettes may be beneficial for smokers who use them to completely and promptly quit smoking, but they are not currently approved smoking cessation aids. Better quality evidence is needed regarding the health impact of e‐cigarette use, their safety and efficacy for smoking cessation, and effective regulation. Registration: Systematic review: PROSPERO, CRD42020200673 (prospective).

Emily Banks · Amelia Yazidjoglou · Sinan Brown · Mai Nguyen · Melonie Martin · Katie Beckwith · Amanda Daluwatta · Sai Campbell · Grace Joshy

Opioid medications may provide very small benefits for people with osteoarthritis, but also increase the risk of adverse events

Christina Abdel Shaheed · Wasim Awal · Geoffrey Zhang · Stephen E Gilbert · Daniel Gallacher · Andrew McLachlan · Richard O Day · Giovanni E Ferreira · Caitlin MP Jones · Harbeer Ahedi · Mamata Tamrakar · Fiona M Blyth · Fiona Stanaway · Christopher G Maher

Objective: To evaluate the efficacy and safety of paracetamol as an analgesic medication in a range of painful conditions. Study design: Systematic review of systematic reviews of the analgesic effects of paracetamol in randomised, placebo‐controlled trials. Conduct of systematic reviews was assessed with AMSTAR‐2; confidence in effect estimates (quality of evidence) was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Data sources: MEDLINE, EMBASE, PsycINFO, Cochrane Database of Systematic Reviews; systematic reviews published 1 January 2010 – 30 April 2020. Data synthesis: We extracted pain and adverse events outcomes from 36 systematic reviews that assessed the efficacy of paracetamol in 44 painful conditions. Continuous pain outcomes were expressed as mean differences (MDs; standardised 0–10‐point scale); dichotomous outcomes were expressed as risk ratios (RRs). There is high quality evidence that paracetamol provides modest pain relief for people with knee or hip osteoarthritis (MD, –0.3 points; 95% CI, –0.6 to –0.1 points) and after craniotomy (MD, –0.8 points; 95% CI, –1.4 to –0.2 points); there is moderate quality evidence for its efficacy in tension‐type headache (pain‐free at 2 hours: RR, 1.3; 95% CI, 1.1–1.4) and perineal pain soon after childbirth (patients experiencing 50% pain relief: RR, 2.4; 95% CI, 1.5–3.8). There is high quality evidence that paracetamol is not effective for relieving acute low back pain (MD, 0.2 points; 95% CI, –0.1 to 0.4 points). Evidence regarding efficacy in other conditions was of low or very low quality. Frequency of adverse events was generally similar for people receiving placebo or paracetamol, except that transient elevation of blood liver enzyme levels was more frequent during repeated administration of paracetamol to patients with spinal pain (RR, 3.8; 95% CI, 1.9–7.4). Conclusions: For most conditions, evidence regarding the effectiveness of paracetamol is insufficient for drawing firm conclusions. Evidence for its efficacy in four conditions was moderate to strong, and there is strong evidence that paracetamol is not effective for reducing acute low back pain. Investigations that evaluate more typical dosing regimens are required. PROSPERO registration: CRD42015029282 (prospective).

Christina Abdel Shaheed · Giovanni E Ferreira · Alissa Dmitritchenko · Andrew J McLachlan · Richard O Day · Bruno Saragiotto · Christine Lin · Vicki Langendyk · Fiona Stanaway · Jane Latimer · Steven Kamper · Hanan McLachlan · Harbeer Ahedi · Christopher G Maher

Objective: To synthesise what is known about women combining motherhood and a career in medicine by examining the published research into their experiences and perspectives. Study design: We reviewed peer‐reviewed articles published or available in English reporting original research into motherhood and medicine and published during 2008–2019. Two researchers screened each abstract and independently reviewed full text articles. Study quality was assessed. Data sources: CINAHL, MEDLINE, PsycINFO, Web of Science, and Scopus abstract databases. Data synthesis: The database search identified 4200 articles; after screening and full text assessment, we undertook an integrative review synthesis of the 35 articles that met our inclusion criteria. Conclusions: Three core themes were identified: Motherhood: the impact of being a doctor on raising children; Medicine: the impact of being a mother on a medical career; and Combining motherhood and medicine: strategies and policies. Several structural and attitudinal barriers to women pursuing both medical careers and motherhood were identified. It was often reported that women prioritise career advancement by delaying starting a family, and that female doctors believed that career progression would be slowed by motherhood. Few evaluations of policies for supporting pregnant doctors, providing maternity leave, and assisting their return to work after giving birth have been published. We did not find any relevant studies undertaken in Australia or New Zealand, nor any studies with a focus on community‐based medicine or intervention studies. Prospective investigations and rigorous evaluations of policies and support mechanisms in different medical specialties would be appropriate. Protocol registration: PROSPERO CRD42019116228.

Rebekah Hoffman · Judy Mullan · Marisa Nguyen · Andrew D Bonney

Objective: To synthesise quantitative data on the effects of rural background and experience in rural areas during medical training on the likelihood of general practitioners practising and remaining in rural areas. Study design: Systematic review and meta‐analysis of the effects of rural pipeline factors (rural background; rural clinical and education experience during undergraduate and postgraduate/vocational training) on likelihood of later general practice in rural areas. Data sources: MEDLINE (Ovid), EMBASE, Informit Health Collection, and ERIC electronic database records published to September 2018; bibliographies of retrieved articles; grey literature. Data synthesis: Of 6709 publications identified by our search, 27 observational studies were eligible for inclusion in our systematic review; when appropriate, data were pooled in random effects models for meta‐analysis. Study quality, assessed with the Newcastle–Ottawa scale, was very good or good for 24 studies, satisfactory for two, and unsatisfactory for one. Meta‐analysis indicated that GPs practising in rural communities was significantly associated with having a rural background (odds ratio [OR], 2.71; 95% CI, 2.12–3.46; ten studies) and with rural clinical experience during undergraduate (OR, 1.75; 95% CI, 1.48–2.08; five studies) and postgraduate training (OR, 4.57; 95% CI, 2.80–7.46; eight studies). Conclusion: GPs with rural backgrounds or rural experience during undergraduate or postgraduate medical training are more likely to practise in rural areas. The effects of multiple rural pipeline factors may be cumulative, and the duration of an experience influences the likelihood of a GP commencing and remaining in rural general practice. These findings could inform government‐led initiatives to support an adequate rural GP workforce. Protocol registration: PROSPERO, CRD42017074943 (updated 1 February 2018).

Jessica Ogden · Scott Preston · Riitta L Partanen · Remo Ostini · Peter Coxeter

Greater investment is needed to support eye health coordinators, community-based liaison officers, and family members and carers

Aryati Yashadhana · Ling Lee · Jessica Massie · Anthea Burnett

FC testing of patients with lower gastrointestinal symptoms could reduce the number with functional disorders undergoing colonoscopy

Yoon‐Kyo An · David Prince · Fergus Gardiner · Teresa Neeman · Ecushla C Linedale · Jane M Andrews · Susan Connor · Jakob Begun

There is no strong evidence that first-line therapy with intravenous iron is superior to oral administration

Alaa Qassim · Rosalie M Grivell · Amanda Henry · Giselle Kidson‐Gerber · Antonia Shand · Luke E Grzeskowiak

Organ donations from people at increased risk but with negative test results could expand the donor pool

Karen MJ Waller · Nicole L De La Mata · Patrick J Kelly · Vidiya Ramachandran · William D Rawlinson · Kate R Wyburn · Angela C Webster

Early identification of GBS patients at risk of respiratory failure could reduce the rates of adverse outcomes associated with delayed intubation

Cameron Green · Tess Baker · Ashwin Subramaniam

Objectives: Codeine dependence is a significant public health problem, motivating the recent rescheduling of codeine in Australia (1 February 2018). To provide information for informing clinical responses, we undertook a systematic review of what is known about identifying and treating codeine dependence. Study design: Articles published in English that described people who were codeine-dependent or a clinical approach to treating people who were codeine-dependent, without restriction on year of publication, were reviewed. Articles not including empirical data were excluded. One researcher screened each abstract; two researchers independently reviewed full text articles. Study quality was assessed, and data were extracted with standardised tools. Data sources: MEDLINE and EMBASE were searched for relevant publications on 22 November 2016. The reference lists of eligible studies were searched to identify further relevant publications. 2150 articles were initially identified, of which 41 were eligible for inclusion in our analysis. Data synthesis: Studies consistently reported specific characteristics associated with codeine dependence, including mental health comorbidity and escalation of codeine use attributed to psychiatric problems. Case reports and series described codeine dependence masked by complications associated with overusing simple analgesics and delayed detection. Ten studies described the treatment of codeine dependence. Three reports identified a role for behavioural therapy; the efficacy of CYP inhibitors in a small open label trial was not confirmed in a randomised controlled trial; four case series/chart reviews described opioid agonist therapy and medicated inpatient withdrawal; two qualitative studies identified barriers related to perceptions of codeine-dependent people and treatment providers, and confirmed positive perceptions and treatment outcomes achieved with opioid agonist treatments. Conclusion: Strategies for identifying problematic codeine use are needed. Identifying codeine dependence in clinical settings is often delayed, contributing to serious morbidity. Commonly described approaches for managing codeine dependence include opioid taper, opioid agonist treatment, and psychological therapies. These approaches are consistent with published evidence for pharmaceutical opioid dependence treatment and with broader frameworks for treating opioid dependence. PROSPERO registration: CRD42016052129.

Suzanne Nielsen · Tim MacDonald · Jacinta L Johnson

Further action to reduce salt consumption in Australia and robust monitoring of population salt intake are needed

Mary-Anne Land · Bruce C Neal · Claire Johnson · Caryl A Nowson · Claire Margerison · Kristina S Petersen

Non-bacteraemic CAP constitutes the largest burden of pneumococcal disease in adults

J Kevin Yin · Sanjay H Jayasinghe · Patrick G Charles · Catherine King · Clayton K Chiu · Robert I Menzies · Peter B McIntyre

Moderate quality evidence supports its value, but the best route of administration and preparation remain to be established

Paul Moayyedi · Yuhong Yuan · Harith Baharith · Alexander C Ford

Acrophobia is a chronic disorder that may have a serious impact on people’s lives

Bruce Arroll · Henry B Wallace · Vicki Mount · Stephen P Humm · Douglas W Kingsford

Given the importance of spirometry testing on respiratory diagnosis and treatment, there is an urgent need for accurate and validated reference values for Indigenous Australians

Tamara L Blake · Anne B Chang · Helen L Petsky · Leanne T Rodwell · Michael G Brown · Debra C Hill · Bruce Thompson · Margaret S McElrea

There is a paucity of evidence to implicate statin therapy as a well established risk factor or causal mechanism for tendon rupture in the general population

Andrew J Teichtahl MB BS(Hons), FRACP, PhD · Sharmayne RE Brady MB BS(Hons), BMedSc(Hons), FRACP · Donna M Urquhart BPhysio, PhD · Anita E Wluka MB BS, FRACP, PhD · Yuanyuan Wang MB BS, MD, PhD · Jonathan E Shaw MB ChB, MD, FRACP · Flavia M Cicuttini MB BS, FRACP, PhD

Benefits go beyond the competencies achievable with adequate supervision and mentoring

Louise Young MPsychEd, PhD · Sarah L Larkins MB BS, MPH · Tarun K Sen Gupta MB BS, FACRRM, PhD · Suzanne H McKenzie MB BS, MMedSci, FRACGP · Rebecca J Evans BSptExSci(Hons), GradCertGovernancePolicy · Michael J Crowe BSc(Mgmt), MIT, PhD · Elizabeth J Ware BSc, DipEd, GradCertClinEd

While the quality of data in the peer-reviewed literature has improved over time, there are still some important gaps in the evidence. The findings of this study provide a framework to allow Indigenous communities, researchers, funding bodies and the NHMRC to consider priorities for future research.

Peter S Azzopardi MB BS, MEpi, FRACP · Elissa C Kennedy MPH, MB BS · George C Patton MB BS, MD, FRANZCP · Robert Power BSc(Econ), PhD, PGCE · Robert D Roseby MB BS(Hons), FRACP · Susan M Sawyer MB BS, MD, FRACP · Alex D Brown BMed, MPH, PhD