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Cancer Research letters 2 March 2020 Free

Comparison of colonic neoplasia detection rates in patients screened inside and outside the National Bowel Cancer Screening Program

Colorectal cancer is an important cause of morbidity and mortality in Australia.1 The National Bowel Cancer Screening Program (NBCSP) aims to detect the disease early by offering faecal occult blood testing (faecal immunochemical test, FIT) to people aged 50–74 years.2 The expansion of the NBCSP has been paralleled by increased numbers of FITs outside the program (community‐initiated FITs) for a number of reasons, including the presence of symptoms. We investigated whether colonoscopy services should provide endoscopies to patients with positive FIT results with the same priority, regardless of whether the test was instigated by the NBCSP, by analysing data from the Newcastle Direct Access Colonoscopy Service (DACS) for the period 2014–18. The DACS manages all patients in the same manner: a positive FIT result leads to assessment for colonoscopy.3,4 Ethics approval was granted by the Hunter New England Human Research Ethics Committee (reference, AU201608‐01). All data were recorded prospectively. Findings were categorised according to surveillance categories endorsed by the Gastroenterological Society of Australia and the Colorectal Surgical Society of Australia and New Zealand.5 Data accuracy was confirmed by reviewing the primary sources for 10% of patients. We identified 2693 patients referred for screening colonoscopy between 1 July 2014 and 30 June 2018; 1439 (53%) had had community‐initiated FITs (Box 1). After excluding 318 patients who did not attend or were lost to follow‐up (community‐initiated, 200; NBCSP, 118) and ten patients with poor bowel preparation and no follow‐up colonoscopy during the study period, 2365 complete screening colonoscopy outcomes were analysed: 1233 following community‐initiated and 1132 following NBCSP testing. With these sample sizes, the study had 80% power to detect differences in colonic neoplasia rate ranging from 16 percentage points (assumed prevalence, 50%) to two percentage points (assumed prevalence, 3%). Z‐tests were used to calculate P values, and Wald tests (two‐tailed) for calculating confidence intervals (CIs) for the differences between the two groups. Differences between the two groups in the proportion of patients with each specific finding are presented with 99% asymptotic CIs to control for multiple testing. Colonoscopy quality was high: the completion rate (defined as either caecal intubation, reaching an ileocolic anastomosis, or reaching an obstructing mass lesion) was 97.1% (community‐initiated, 1193 of 1233, 96.8%; NBCSP, 1104 of 1132, 97.5%), and the adenoma detection rate was 49%, exceeding international benchmarks for either symptomatic or screening patients (for screening: at least 25% in men and 15% in women;6 for populations enriched with patients with positive FIT results: 35%7). The rate of colorectal neoplasia (malignant or pre‐malignant) was similar in the two groups. Importantly, the difference in the rates of adenocarcinoma was not statistically significant (community‐initiated, 4.0%; NBCSP, 2.7%; difference, 1.3 percentage points [99% CI, –0.6 to 3.3 percentage points]; P = 0.09). The only statistically significant difference by type was that the incidence of high risk adenoma was slightly higher in the NBCSP group (22.9% v 17.2%; difference, 5.7 percentage points [99% CI, 1.4–10 percentage points]; P < 0.001) (Box 2). We found that the incidence and detection rates of colorectal neoplasia in people aged 50–74 years were similar for people with positive results for NBCSP or community‐initiated FITs. The large population in our study means that it provides colonoscopy providers strong evidence that evaluation should be performed equally promptly for patients with positive results from NBSCP and community‐initiated FITs. Box 1 – Demographic characteristics of the 2693 patients with positive faecal immunochemical test results and referred to the Newcastle Direct Access Colonoscopy Service for colonoscopy, 2014–18 Faecal immunochemical test Total Community‐initiated NBCSP Number of patients 1439 1254 2693 Sex Women 675 559 1234 Men 764 695 1459 Age (years), mean (SD) 62.9 (6.8) 63.2 (7.3) 63.1 (7.0) Numbers of patients 50–54 years 213 147 360 55–59 years 280 271 551 60–64 years 312 212 524 65–69 years 330 288 618 70–74 years 304 336 640 NBCSP = National Bowel Cancer Screening Program; SD = standard deviation. Box 2 – Differences in colonoscopy outcomes for people who had community‐initiated (1233 patients) or NBCSP (1132 patients) faecal immunochemical tests CI = confidence interval; NBCSP = National Bowel Cancer Screening Program. *Large sessile polyps (> 2 cm) or malignant polyps. † Between values for community‐initiated and NBCSP groups.

Simon Whitcher · Monique Magnusson · Jon Gani · Christopher Oldmeadow · Peter G Pockney

Mja2 50508
Women's health Letters 13 January 2020 Free

Influenza and pertussis vaccination of women during pregnancy in Victoria, 2015–2017

To the Editor: As reported by Rowe and colleagues1 in their retrospective analysis of maternal immunisation, uptake of influenza and acellular pertussis vaccines among pregnant women remains unacceptably low. One contributing factor may be inconsistent messaging. Historically, vaccine manufacturers have included precautions about the lack of data on use in pregnancy in their product information sheets. Such precautions have been shown to lead to vaccination hesitancy and refusal among pregnant women.2,3 In contrast, the current edition of the Australian Immunisation Handbook states: “Pregnant women are routinely recommended to receive influenza vaccine … and pertussis‐containing vaccine”.4 In 2018, the Therapeutic Goods Administration asked its Advisory Committee on Vaccines to provide independent expert advice on the available safety data on influenza vaccination in pregnancy with regards to the pregnancy category of influenza vaccines. The Advisory Committee on Vaccines advised that “adoption of Australian Pregnancy Category A should be considered by sponsors for certain inactivated influenza vaccines”.5 Pregnancy Category A signals to doctors and the public that the vaccine has been used by large numbers of expectant mothers with no evidence of harm to their babies. This is in line with the Australian Immunisation Handbook: “Clinical trial data and observational studies show no increased risk of congenital defects or adverse effects in the fetuses of women who received influenza vaccine during pregnancy”.4 Following the publication of the Advisory Committee on Vaccines statement, two of the four adult influenza vaccines and one of the two acellular pertussis vaccines used to vaccinate pregnant women in Australia have changed their pregnancy category to Category A. These changes show that the Australian regulator is receptive to feedback from the medical community on how to improve immunisation rates. Hopefully, the reclassification of the pregnancy category of these vaccines will translate into increased maternal uptake and better outcomes for Australian mothers and babies.

Heidi Shukralla · Michael Coory

Mja2 50429
Women's health Letters 18 November 2019 Free

Influenza and pertussis vaccination of women during pregnancy in Victoria, 2015–2017

To the Editor: We read with interest the recent publication by Rowe and colleagues.1 The authors reported low influenza vaccine coverage (39%) among pregnant women in Victoria from 2015 to 2017. Individual‐level factors associated with this finding included greater maternal age, primigravidity, early antenatal care and GP‐led antenatal care.1 As the authors accurately concluded, integrating vaccine delivery into antenatal care pathways is important to improve pregnant women's vaccination coverage.1 Our team reported on this previously, with coverage approximating 90% achieved by introducing standing orders for midwives.2 In collaboration with key stakeholders from six Victorian maternity services, a Monash University‐led project funded by Better Care Victoria is currently underway to implement integrated vaccination strategies and measure the cost and magnitude of improvement in maternal immunisation coverage in Victoria,3 the results of which will be available by the end of 2019. One of the key findings in the article by Rowe and colleagues1 is higher odds of influenza vaccination in women who gave birth after 37 weeks' gestation compared with women who gave birth before 28 weeks (adjusted odds ratio [aOR], 4.74; 95% CI, 3.54–6.35). A similar finding was reported for women who gave birth between 28 and 36 weeks gestation (aOR, 4.13; 95% CI, 3.07–5.56).1 This finding has two important implications. Firstly, it may indicate a potential beneficial effect of influenza vaccine received by pregnant women in reducing pre‐term birth (< 37 weeks' gestation). This is consistent with a recent systematic review and meta‐analysis that reported inactivated influenza vaccine to have a protective effect against pre‐term birth and low birth weight.4 Secondly, this finding may serve as an opportunity to emphasise the safety and benefits of influenza vaccines on perinatal outcomes. As the authors alluded to in their discussion, pregnant women tend to view influenza as primarily a health risk for themselves rather than for their infants.1 Given the importance of health care providers' recommendations in encouraging influenza vaccination among pregnant women, timely dissemination of the potential benefit in lowering the chance of pre‐term birth could further empower health care providers to recommend influenza vaccines to pregnant women.5

Khai Lin Kong · Michelle L Giles · Euan M Wallace

Mja2 50387
Environmental health Perspectives 14 November 2019 Free

The 2019 report of the MJA–Lancet Countdown on health and climate change: a turbulent year with mixed progress

The lack of national policy means that Australia remains at significant risk of declines in health due to climate change — substantial and sustained national action is urgently required

Paul J Beggs · Ying Zhang · Hilary Bambrick · Helen L Berry · Martina K Linnenluecke · Stefan Trueck · Peng Bi · Sinead M Boylan · Donna Green · Yuming Guo · Ivan C Hanigan · Fay H Johnston · Diana L Madden · Arunima Malik · Geoffrey G Morgan · Sarah Perkins‐Kirkpatrick · Lucie Rychetnik · Mark Stevenson · Nick Watts · Anthony G Capon

Mja2 50405
Environmental health Letters 4 November 2019 Free

Increasing illicit use of nitrous oxide in presentations to NSW emergency departments

To the Editor: Recreational use of nitrous oxide is increasing among regular drug users in Australia1 and internationally.2 In a New South Wales survey of participants who had used ecstasy or other stimulants in the past 6 months, 75% of respondents reported recent use of nitrous oxide in 2018, up from 20% in 2013.3 Nitrous oxide use while bingeing on stimulants rose from 4% of respondents in 2013 to 16% in 2017.4,5 Access to nitrous oxide has been facilitated by businesses offering 24/7 delivery of large quantities of canisters, ostensibly for whipping cream.6 We examined presentations to 60 emergency departments (EDs) across NSW from January 2012 to December 2018 (covering about 82% of all NSW ED presentations) in which the patient reported inhaling nitrous oxide outside a therapeutic setting. We extracted records from the Rapid Emergency Department Data for Surveillance (REDDS) dataset in which the person was aged 16 years or over and “nitrous oxide” or related terms were mentioned in the presenting problem, nursing assessment or diagnosis fields. We manually reviewed records for inclusion; this method may underestimate true presentation counts. ED presentations fitting the criteria were infrequent (n = 118) but increased over time, particularly from 2016 to 2018 (Box). Most presentations were in persons aged 16–30 years (n = 98, 83%) and just over half were men (n = 66, 56%). Almost half indicated polydrug use (n = 54, 46%), and one quarter indicated chronic or heavy use of nitrous oxide (n = 28, 24%). Consistent with the case literature,7 presenting problems and diagnoses included injury (n = 15, 13%), neurological symptoms (n = 14, 12%), loss of consciousness or syncope (n = 13, 11%), respiratory arrest (n = 2, 2%), self‐harm or suicidal ideation (n = 16, 14%), or other mental health conditions (n = 28, 24%). This increase in presentations may reflect changes in the underlying population or in data collection, rather than changes in drug use. However, the trend is consistent with drug use survey findings,1,3 suggesting that recreational nitrous oxide use may be an emerging health problem in Australia. Clinicians should include nitrous oxide use as part of a drug history, consider potential use among young patients presenting with neurological symptoms resembling B12 deficiency, and educate users on the health impacts, harm minimisation strategies and available support services. NSW Health is educating at‐risk groups through multilingual fact sheets8 and targeted social media and other messaging. This report is the result of an investigation carried out by the NSW Ministry of Health under the provisions of the NSW Health Administration Act 1982; therefore, specific ethics approval was not required. Data were sourced from the REDDS, which is maintained by the Ministry of Health, and were analysed by Ministry of Health staff for the purpose of the investigation. Box – Emergency department presentations in New South Wales in which the patient reported inhaling nitrous oxide in a non‐therapeutic setting (from January 2012 to December 2018) Data source: Rapid Emergency Department Data for Surveillance (REDDS), held by NSW Ministry of Health.

Anna Bethmont · Claire E Harper · Betty SH Chan · Andrew H Dawson · Jeremy McAnulty

Mja2 50377

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