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Environmental health

Cancer Guideline Summary 2 December 2018 Free

Methods of melanoma detection and of skin monitoring for individuals at high risk of melanoma: new Australian clinical practice guidelines

Early detection of primary melanoma remains an effective strategy to reduce melanoma‐related mortality. This article presents multiple methods of monitoring the skin in patients at high risk of developing melanoma. Determining the relative indications for each method and how each method should be introduced into the surveillance of a patient requires careful consideration and an individualised approach.TBP and SDDI provide different methods for the detection of change in the context of melanoma surveillance and, therefore, these methods should be applied to different, but overlapping (ie, non‐mutually exclusive), settings. TBP permits identification of most new or changed lesions on the skin surface. TBP is particularly suited to patients at elevated risk with high naevus counts and multiple dysplastic naevi. SDDI fulfils a different need for monitoring one or many individual flat lesions of concern that lack diagnostic clinical or dermoscopic features of melanoma. Of note, both TBP and SDDI rely on patient adherence to follow‐up appointments, and poor compliance would thus compromise the benefits that these methods confer. It is therefore crucial to emphasise to patients the importance of regular follow‐up.Much of the existing literature has been conducted in high risk patient cohorts; however, these techniques, particularly TBP, are less tested in lower risk populations and may not have the same value. To undertake a randomised controlled trial evaluating these methods in high risk patients would present ethical difficulties; nevertheless, a randomised controlled trial of TBP and SDDI in a large cohort of lower risk individuals might be justifiable. Further research is needed to elucidate the optimal risk thresholds for the introduction of both TBP and SDDI to surveillance programs. Research regarding cost‐effectiveness for the above‐mentioned diagnostic aids in different risk cohorts is also required. Specialised surveillance with TBP and SDDI has been shown to be a cost‐effective strategy for the management of individuals at high risk of melanoma. Notwithstanding the demonstrated cost‐effectiveness in high risk patients, these modalities are not currently reimbursed by the Australian Medicare system.Furthermore, RCM may be used to assist with the identification of melanoma for suspicious lesions located on the head and neck, lesions in areas that are subject to chronic sun exposure, lesions dermoscopically typified by regression and amelanotic tumours. At present, there is insufficient evidence to recommend the routine use of automated instruments for the clinical diagnosis of melanoma. Nonetheless, the use of both automatic instruments and of artificial intelligence for the clinical diagnosis of melanoma represents an exciting area for future research. Further research should also be directed at assessing the performance of new methods of skin imaging, such as three dimensional imaging, the role of teledermatology using TBP, dermoscopy and SDDI, and skin self‐assessment of suspicious lesions using smartphone applications. Of note, TBP also has the potential to aid skin self‐examination; yet, evidence to date would appear to indicate limited uptake by consumers. An important area for future research might also be to explore barriers to and determinants of skin self‐examination, and to investigate appropriate methods of educating consumers with respect to melanoma surveillance.

Nikki R Adler · John W Kelly · Pascale Guitera · Scott W Menzies · Alex J Chamberlain · Paul Fishburn · Alison E Button‐Sloan · Clinton Heal · H Peter Soyer · John F Thompson

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Environmental health Perspective 29 November 2018 Free

The MJA–Lancet Countdown on health and climate change: Australian policy inaction threatens lives

Climate plays an important role in human health and it is well established that climate change can have very significant impacts in this regard. In partnership with The Lancet and the MJA, we present the inaugural Australian Countdown assessment of progress on climate change and health. This comprehensive assessment examines 41 indicators across five broad sections: climate change impacts, exposures and vulnerability; adaptation, planning and resilience for health; mitigation actions and health co-benefits; economics and finance; and public and political engagement. These indicators and the methods used for each are largely consistent with those of the Lancet Countdown global assessment published in October 2017, but with an Australian focus. Significant developments include the addition of a new indicator on mental health. Overall, we find that Australia is vulnerable to the impacts of climate change on health, and that policy inaction in this regard threatens Australian lives. In a number of respects, Australia has gone backwards and now lags behind other high income countries such as Germany and the United Kingdom. Examples include the persistence of a very high carbon-intensive energy system in Australia, and its slow transition to renewables and low carbon electricity generation. However, we also find some examples of good progress, such as heatwave response planning. Given the overall poor state of progress on climate change and health in Australia, this country now has an enormous opportunity to take action and protect human health and lives. Australia has the technical knowhow and intellect to do this, and our annual updates of this assessment will track Australia’s engagement with and progress on this vitally important issue.

Ying Zhang · Paul J Beggs · Hilary Bambrick · Helen L Berry · Martina K Linnenluecke · Stefan Trueck · Robyn Alders · Peng Bi · Sinead M Boylan · Donna Green · Yuming Guo · Ivan C Hanigan · Elizabeth G Hanna · Arunima Malik · Geoffrey G Morgan · Mark Stevenson · Shilu Tong · Nick Watts · Anthony G Capon

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Environmental health Research 26 November 2018 Free

Pregabalin misuse‐related ambulance attendances in Victoria, 2012–2017: characteristics of patients and attendances

The known: Pregabalin misuse is increasing worldwide, and is associated with acute psychiatric and medical harms, but patterns of pregabalin misuse in Australia have not been reported. The new: The rate of pregabalin‐related ambulance attendances has increased tenfold since 2012, associated with an increase in the national prescription rate. Patients frequently misused pregabalin with other sedatives, particularly benzodiazepines, and almost 40% of misuse‐related events requiring paramedic attendance were suicide attempts. The implications: Caution is required when prescribing pregabalin for patients using other sedatives. Misuse might be reduced by restricting dispensing of the drug.

Rose Crossin · Debbie Scott · Shalini Arunogiri · Karen Smith · Paul M Dietze · Dan I Lubman

Mja2 12036
Environmental health Letters 19 November 2018 Free

Planetary health: the Australian chapter

To the Editor: Doctors for the Environment Australia welcomed MJA’s recent planetary health issue.1 It could not come at a more crucial time. Human health and the environment are inextricably linked, and medical professionals have a vital role in actively protecting health through care of the environment. However, it was disappointing that little emphasis was given to the need to significantly mitigate greenhouse gas emissions, and to the important advocacy role that medical professionals share to raise awareness of the urgency of delivering Australia’s Paris Agreement commitment. Global temperature rises greater than 1.5–2°C will adversely affect planetary health, sustainable development and nearly all future health goals.2 Further temperature increases will be catastrophic to sea level rises and the food and ecosystems on which human life depends. While countries such as France and China move ahead on mitigation measures, Australia is, at best, slow to understand the urgency or, at worst, an active global laggard. Australia is one of the OECD countries most vulnerable to climate change;3 it is among the top seven countries contributing to 60% of the world’s biodiversity loss,4 and yet it is not transitioning jobs or future wealth towards sustainable energy. All while human-induced environmental threats to the global riches of the Great Barrier Reef, the Northern Territory and the Pilliga and Tarkine forests are fast becoming this generation’s environmental legacy. Doctors should urgently raise awareness of the threats to health from climate change, advocate to mitigate the threats, and show in practice that transitioning to low carbon societies in energy, diet and transport have health co-benefits. The greatest global health threat of the 21st century posed by climate change is also health’s greatest opportunity.5 Australian medical staff can systematically push the planetary health agenda into university training, specialist colleges, hospitals, clinics and communities. We are well placed to do so.

Selina N Lo · Kaiya Ferguson · Eugenie Kayak · Kingsley Faulkner

Environmental health Letters 19 November 2018 Free

The three A’s of colonoscopy referral

To the Editor:The National Bowel Cancer Screening Program will reduce the burden of colorectal cancer, saving lives and money.1 The benefits of the program, however, rely on both public and private sectors to deliver colonoscopy, surgery and, if necessary, advanced cancer care. Public confidence in the whole program is likely to be affected by the affordability, ability and availability of these frontline services. Some public hospitals are unable to reliably deliver timely colonoscopy (ie, within 120 days).2,3 Private practice is an efficient and, for many, affordable option, but there is considerable variation in price. Furthermore, pricing information is often not readily available before referral and can be complicated by multiple separate fees. In contrast, the public hospital system is affordable (free), but there may be issues of availability due to waiting times. The ability of the colonoscopist is relevant to both settings, with adenoma detection rate a well validated quality indicator.4 To test the performance of a discounted, anaesthetist-assisted, private colonoscopy service for high-risk public patients, we conducted the following observational study in a metropolitan practice. Through efficiencies and cost sharing, we provided colonoscopy for a discounted out-of-pocket fee of $310 ($300 for the colonoscopy plus $10 for the bowel preparation kit). We performed 100 colonoscopies and diagnosed seven cancers, with an adenoma detection rate of 66% and a median wait of 29 days. These colonoscopies, if performed publicly, would have cost the state budget over $190 000, at approximately $1900 per colonoscopy (Margaret Clark, South Australia Health, personal communication; July 2018). In contrast, the total cost of this program was about $94 895, comprising the total patient payment of $31 000 plus the total combined bulk-billed fee for clinicopathological services of $63 895. This program did not cost-shift, it cost-saved about $95 105. Private and public services should provide current information to general practitioners, patients and government concerning their affordability (total out-of-pocket fee), ability (http://recert.gesa.org.au/recertified.php) and availability (waiting time from GP referral to colonoscopy). The $310 out-of-pocket fee is unlikely to be the equilibrium price for self-funded colonoscopy in Australia and investment in public colonoscopy remains important. Nevertheless, we suggest that patient autonomy and access would be improved by real time accurate information about their colonoscopy options to allow them to make a rational choice. This would help optimise the benefits of the National Bowel Cancer Screening Program and allow public and private sectors to work together to eradicate bowel cancer death in Australia.

Peter Bampton · Tarik Sammour · Gregor JE Brown · David G Hewett · Daniel L Worthley

Cancer Research 24 September 2018 Free

Surveillance improves survival of patients with hepatocellular carcinoma: a prospective population-based study

Survival may be improved by surveillance, as it enables curative therapies to be initiated

Thai P Hong · Paul J Gow · Michael Fink · Anouk Dev · Stuart K Roberts · Amanda Nicoll · John S Lubel · Ian Kronborg · Niranjan Arachchi · Marno Ryan · William W Kemp · Virginia Knight · Vijaya Sundararajan · Paul Desmond · Alexander JV Thompson · Sally J Bell

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Environmental health Letters 20 August 2018 Free

An era of untreatable gonorrhoea?

To the Editor: We are concerned about the emergence of antibiotic-resistant gonorrhoea in Australia. On 17 April 2018, the Commonwealth’s Chief Medical Officer Brendan Murphy released a statement about two cases of multidrug-resistant gonorrhoea that had recently been detected in Australia1 — at least one of these patients acquired the infection in Southeast Asia. These particular cases were similar to the one recently reported in the United Kingdom,2 where the patient was reported3 as having high level resistance to azithromycin and to ceftriaxone — the cornerstone of treatment. Also notable in that case was treatment failure using spectinomycin, with ongoing detection of the bacterium on throat swab. Treatment with intravenous ertapenem was successful. It should be of concern that gonorrhoea may only have the option of intravenous treatment, but the real problem here is that we may be on the precipice of untreatable gonorrhoea. With almost 750 000 short term resident returns every month,4 and over 200 000 of these being returns from Southeast Asia, the likelihood of repeated introductions is real. In the current context of rising gonorrhoea rates in Australia,5 further importation, transmission and spread of these resistant organisms will add substantial challenges to the disease control, especially in men who have sex with men and in Indigenous Australians. Such spread will incur significant health and health care costs for the sexual and reproductive health of Australians. There is an urgent need for all treating doctors to ensure that swabs for culture are taken for all symptomatic patients, as well as for those with an initial positive polymerase chain reaction result; for travellers to be aware of the risks of having unprotected sex; and for any multidrug-resistant patients and contacts to be referred for expert advice to ensure testing and treatment.

Brett Sutton · Mihaela Ivan

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