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    Advancing menopause care in Australia: barriers and opportunities

    Susan R Davis and Karen Magraith
    Med J Aust 2023; 218 (11): . || doi: 10.5694/mja2.51981
    Published online: 19 June 2023

    Lack of clinician knowledge, poor access to services, negative attitudes, and lagging research have led to substandard menopause‐related health care

    The menopause is the permanent loss of ovarian reproductive function. Irrespective of symptoms, menopause causes silent biological changes that may increase women's risks of cardiovascular disease, diabetes, osteoporosis, and some cancers.1 Consequently, it should be expected that health care providers, especially general practitioners, are equipped to provide evidence‐based menopause advice to the 3.28 million Australian women aged 40–59 years. Sadly, this is not the case.

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    • 1 Monash University, Melbourne, VIC
    • 2 University of Tasmania, Hobart, TAS


    Correspondence: susan.davis@monash.edu


    Open access:

    Open access publishing facilitated by Monash University, as part of the Wiley ‐ Monash University agreement via the Council of Australian University Librarians.

    Competing interests:

    Susan Davis reports honoraria from Besins Healthcare, Mayne Pharma, Pfizer Australia, BioFemme, Lawley Pharmaceuticals, Southern Star Research, and Que Oncology. She has served on advisory boards for Mayne Pharma, Gedeon Richter, Astellas Pharmaceuticals, Roche Diagnostics, Theramex, and Abbott Laboratories; and is an institutional investigator for Que Oncology and Ovoca Bio. Karen Magraith has received honoraria for presentations from Mylan, Jean Hailes for Women's Health, and the Australasian Menopause Society.

    • 1. Davis SR, Baber RJ. Treating menopause — MHT and beyond. Nat Rev Endocrinol 2022; 18: 490‐502.
    • 2. Gartoulla P, Worsley R, Bell RJ, Davis SR. Moderate to severe vasomotor and sexual symptoms remain problematic for women aged 60 to 65 years. Menopause 2015; 22: 694‐701.
    • 3. Worsley R, Bell RJ, Gartoulla P, et al. Moderate–severe vasomotor symptoms are associated with moderate–severe depressive symptoms. J Womens Health (Larchmt) 2017; 26: 712‐718.
    • 4. Zheng J, Islam RM, Bell RJ, et al. Prevalence of low sexual desire with associated distress across the adult life span: an Australian cross‐sectional study. J Sex Med 2020; 17: 1885‐1895.
    • 5. Worsley R, Bell RJ, Gartoulla P, Davis SR. Low use of effective and safe therapies for moderate to severe menopausal symptoms: a cross‐sectional community study of Australian women. Menopause 2015; 23: 11‐17.
    • 6. Sowers MR, Zheng H, Jannausch ML, et al. Amount of bone loss in relation to time around the final menstrual period and follicle‐stimulating hormone staging of the transmenopause. J Clin Endocrinol Metab 2010; 95: 2155‐2162.
    • 7. Cooke G, Valenti L, Glasziou P, Britt H. Common general practice presentations and publication frequency. Aust Fam Physician 2013; 42: 65‐68.
    • 8. Davis SR, Herbert D, Reading M, Bell RJ. Health‐care providers’ views of menopause and its management: a qualitative study. Climacteric 2021; 24: 612‐617.
    • 9. Herbert D, Bell RJ, Young K, et al. Australian women's understanding of menopause and its consequences: a qualitative study. Climacteric 2020; 23: 622‐628.
    • 10. North American Menopause Society. The 2012 hormone therapy position statement of the North American Menopause Society. Menopause 2012; 19: 257‐271.
    • 11. Hormone Therapy Position Statement of the North American Menopause Society Advisory Panel. The 2022 hormone therapy position statement of the North American Menopause Society. Menopause 2022; 29: 767‐794.
    • 12. Webber L, Davies M, Anderson R, et al. ESHRE guideline: management of women with premature ovarian insufficiency. Hum Reprod 2016; 31: 926‐937.
    • 13. Vinogradova Y, Coupland C, Hippisley‐Cox J. Use of hormone replacement therapy and risk of venous thromboembolism: nested case‐control studies using the QResearch and CPRD databases. BMJ 2019; 364: k4810.
    • 14. Ortmann O, Beckermann MJ, Inwald EC, et al. Peri‐ and postmenopause — diagnosis and interventions interdisciplinary S3 guideline of the association of the scientific medical societies in Germany (AWMF 015/062): short version. Arch Gynecol Obstet 2020; 302: 763‐777.
    • 15. Adams MR, Register TC, Golden GL, et al. Medroxyprogesterone acetate antagonizes inhibitory effects of conjugated equine estrogens on coronary artery atherosclerosis. Arterioscler Thromb Vasc Biol 1997; 17: 217‐221.
    • 16. Fournier A, Mesrine S, Dossus L, et al. Risk of breast cancer after stopping menopausal hormone therapy in the E3N cohort. Breast Cancer Res Treat 2014; 145: 535‐543.
    • 17. Lobo RA, Archer DF, Kagan R, et al. A 17β‐estradiol‐progesterone oral capsule for vasomotor symptoms in postmenopausal women: a randomized controlled trial. Obstet Gynecol 2018; 132: 161‐170.
    • 18. Effects of hormone replacement therapy on endometrial histology in postmenopausal women. The Postmenopausal Estrogen/Progestin Interventions (PEPI) Trial. The Writing Group for the PEPI Trial. JAMA 1996; 275: 370‐375.
    • 19. Klipping C, Duijkers I, Parke S, et al. Hemostatic effects of a novel estradiol‐based oral contraceptive: an open‐label, randomized, crossover study of estradiol valerate/dienogest versus ethinylestradiol/levonorgestrel. Drugs R D 2011; 11: 159‐170.
    • 20. Morimont L, Haguet H, Dogne JM, et al. Combined oral contraceptives and venous thromboembolism: review and perspective to mitigate the risk. Front Endocrinol (Lausanne) 2021; 12: 769187.
    • 21. Islam RM, Bell RJ, Green S, et al. Safety and efficacy of testosterone for women: a systematic review and meta‐analysis of randomised controlled trial data. Lancet Diabetes Endocrinol 2019; 7: 754‐766.
    • 22. Fooladi E, Bell RJ, Jane F, et al. Testosterone improves antidepressant‐emergent loss of libido in women: findings from a randomized, double‐blind, placebo‐controlled trial. J Sex Med 2014; 11: 831‐839.
    • 23. Davis SR, Baber R, Panay N, et al. Global consensus position statement on the use of testosterone therapy for women. Climacteric 2019; 22: 429‐434.

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      Reimagining medical abortion in Australia: what do we need to do to meet women's needs and ensure ongoing access?

      Danielle Mazza
      Med J Aust 2023; 218 (11): . || doi: 10.5694/mja2.51979
      Published online: 19 June 2023

      There is much to be done to make high quality, accessible medical abortion a reality in Australia

      The overturning of Roe v Wade in the United States has renewed impetus in Australia to ensure the availability of high quality, accessible abortion services. But decriminalisation and the availability of medical abortion do not in and of themselves mandate service delivery or ensure access. Numerous barriers continue to exist. These include issues such as inconsistent abortion laws, over‐regulation, lack of regional level planning and accountability for service delivery, sparse and inconsistent services across the country, inadequate numbers of skilled providers, a lack of training opportunities for the current and future workforce, and consumer concerns such as high costs and difficulty navigating services.

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      • Monash University, Melbourne, VIC


      Correspondence: danielle.mazza@monash.edu


      Open access:

      Open access publishing facilitated by Monash University, as part of the Wiley ‐ Monash University agreement via the Council of Australian University Librarians.

      Competing interests:

      No relevant disclosures.

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        Mortality among people admitted to Australian intensive care units for reasons other than COVID‐19 during the COVID‐19 pandemic: a retrospective cohort study

        Sing Chee Tan, Tess Evans, Matthew L Durie, Paul J Secombe and David Pilcher
        Med J Aust 2023; 218 (10): . || doi: 10.5694/mja2.51933
        Published online: 5 June 2023

        Abstract

        Objective: To investigate in‐hospital mortality among people admitted to Australian intensive care units (ICUs) with conditions other than coronavirus disease 2019 (COVID‐19) during the COVID‐19 pandemic.

        Design: National, multicentre, retrospective cohort study; analysis of data in the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation (ANZICS CORE) Adult Patient Database.

        Setting, participants: Adults (16 years or older) without COVID‐19 admitted to Australian ICUs, 1 January 2016 – 30 June 2022.

        Main outcome measures: All‐cause in‐hospital mortality, unadjusted and relative to the January 2016 value, adjusted for illness severity (Australian and New Zealand Risk of Death [ANZROD] and hospital type), with ICU as a random effect. Points of change in mortality trends (breakpoints) were identified by segmental regression analysis.

        Results: Data for 950 489 eligible admissions to 186 ICUs were available. In‐hospital mortality declined steadily from January 2016 to March 2021 by 0.3% per month (P < 0.001; March 2021 v January 2016: adjusted odds ratio [aOR], 0.70; 95% confidence interval [CI], 0.62–0.80), but rose by 1.4% per month during March 2021 – June 2022 (P < 0.001; June 2022 v January 2016: aOR, 1.03; 95% CI, 0.90–1.17). The rise in mortality continued after the number of COVID‐19‐related ICU admissions had declined; mortality increased in jurisdictions with lower as well as in those with higher numbers of COVID‐19‐related ICU admissions.

        Conclusion: The rise in in‐hospital mortality among people admitted to Australian ICUs with conditions other than COVID‐19 from March 2021 reversed the improvement of the preceding five years. Changes to health service delivery during the pandemic and their consequences should be investigated further.

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        • 1 Northern Hospital Epping, Melbourne, VIC
        • 2 The University of Melbourne, Melbourne, VIC
        • 3 Fiona Stanley Hospital, Perth, WA
        • 4 Melbourne Health, Melbourne, VIC
        • 5 Alice Springs Hospital, Alice Springs, NT
        • 6 Monash University, Melbourne, VIC
        • 7 The Alfred Hospital, Melbourne, VIC
        • 8 Centre for Outcome and Resource Evaluation Australian and New Zealand Intensive Care Society, Melbourne, VIC


        Open access:

        Open access publishing facilitated by The University of Melbourne, as part of the Wiley ‐ The University of Melbourne agreement via the Council of Australian University Librarians.

        Acknowledgements: 

        We thank the Australia New Zealand Intensive Care Society (ANZICS) Centre for Outcomes and Resource Evaluation (CORE) for providing the data we analysed. The authors and the management committees of ANZICS CORE also thank the clinicians, data collectors, and researchers at the contributing sites.

        Competing interests:

        No relevant disclosures.

        • 1. Riley B, Packer M, Gallier S, et al. Acute, non‐COVID related medical admissions during the first wave of COVID‐19: A retrospective comparison of changing patterns of disease. Acute Med 2020; 19: 176‐182.
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        • 3. Corrigan C, Duke G, Millar J, et al; Australian and New Zealand Intensive Care Society Pediatric Study Group; ANZICS Center for Outcome and Resource Evaluation. Admissions of children and adolescents with deliberate self‐harm to intensive care during the SARS‐COV‐2 outbreak in Australia. JAMA Netw Open 2022; 5: e2211692.
        • 4. Fjølner J, Haaland ØA, Jung C, et al. Who gets the ventilator? A multicentre survey of intensivists’ opinions of triage during the first wave of the COVID‐19 pandemic. Acta Anaesthesiol Scand 2022; 66: 859‐868.
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        • 9. Australian and New Zealand Intensive Care Society. ANZICS Centre for Outcomes and Resource Evaluation: 2019 annual report. Melbourne, 2020. https://www.anzics.com.au/wp‐content/uploads/2020/11/2019‐CORE‐Report.pdf (viewed Sept 2022).
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        • 13. Zampieri FG, Bastos LSL, Soares M, et al. The association of the COVID‐19 pandemic and short‐term outcomes of non‐COVID‐19 critically ill patients: an observational cohort study in Brazilian ICUs. Intensive Care Med 2021; 47: 1440‐1449.
        • 14. Indian Registry of IntenSive care (IRIS); Kj Adhikari N, Beane A, Devaprasad D, et al. Impact of COVID‐19 on non‐COVID intensive care unit service utilization, case mix and outcomes: a registry‐based analysis from India. Wellcome Open Res 2021; 6: 159.
        • 15. Bologheanu R, Maleczek M, Laxar D, Kimberger O. Outcomes of non‐COVID‐19 critically ill patients during the COVID‐19 pandemic : a retrospective propensity score‐matched analysis. Wien Klin Wochenschr 2021; 133: 942‐950.
        • 16. Litton E, Bucci T, Chavan S, et al. Surge capacity of Australian intensive care units associated with COVID‐19 admissions. Med J Aust 2020; 212: 463‐467. https://www.mja.com.au/journal/2020/212/10/surge‐capacity‐intensive‐care‐units‐case‐acute‐increase‐demand‐caused‐covid‐19
        • 17. Begum H, Neto AS, Alliegro P, et al. People in intensive care with COVID‐19: demographic and clinical features during the first, second, and third pandemic waves in Australia. Med J Aust 2022; 217: 352‐360. https://www.mja.com.au/journal/2022/217/7/people‐intensive‐care‐covid‐19‐demographic‐and‐clinical‐features‐during‐first
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        • 24. Lyall MJ, Lone NI. Higher clinical acuity and 7‐day hospital mortality in non‐COVID‐19 acute medical admissions: prospective observational study. Emerg Med J 2021; 38: 366‐370.
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          The characteristics of SARS‐CoV‐2‐positive children in Australian hospitals: a PREDICT network study

          Laila Ibrahim, Catherine Wilson, Doris Tham, Mark Corden, Shefali Jani, Michael Zhang, Amit Kochar, Ker Fern Tan, Shane George, Natalie T Phillips, Paul Buntine, Karen Robins‐Browne, Vimuthi Chong, Thomas Georgeson, Anna Lithgow, Sarah Davidson, Sharon O'Brien, Viet Tran and Franz E Babl
          Med J Aust 2023; 218 (10): . || doi: 10.5694/mja2.51934
          Published online: 5 June 2023

          Abstract

          Objectives: To examine the clinical characteristics and short term outcomes for children with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infections who presented to Australian hospitals during 2020 and 2021.

          Design, setting: Retrospective case review study in nineteen hospitals of the Paediatric Research in Emergency Departments International Collaborative (PREDICT) network from all Australian states and territories, including seven major paediatric tertiary centres and eight Victorian hospitals.

          Participants: SARS‐CoV‐2‐positive people under 18 years of age who attended emergency departments or were admitted to hospital during 1 February 2020 – 31 December 2021.

          Main outcome measures: Epidemiological and clinical characteristics, by hospital care type (emergency department [ED] or inpatient care).

          Results: A total of 1193 SARS‐CoV‐2‐positive children and adolescents (527 girls, 44%) attended the participating hospitals (107 in 2020, 1086 in 2021). Their median age was 3.8 years (interquartile range [IQR], 0.8–11.4 years); 63 were Aboriginal or Torres Strait Islander people (5%). Other medical conditions were recorded for 293 children (25%), including asthma (86, 7%) and premature birth (68, 6%). Medical interventions were not required during 795 of 1181 ED presentations (67%); children were discharged directly home in 764 cases (65%) and admitted to hospital in 282 (24%; sixteen to intensive care units). The 384 admissions to hospital (including 102 direct admissions) of 341 children (25 infants under one month of age) included 23 to intensive care (6%); the median length of stay was three days (IQR, 1–9 days). Medical interventions were not required during 261 admissions (68%); 44 children received respiratory support (11%) and 21 COVID‐19‐specific treatments, including antiviral and biologic agents (5%). Being under three months of age (v one year to less than six years: odds ratio [OR], 2.6; 95% confidence interval [CI], 1.7–4.0) and pre‐existing medical conditions (OR, 2.5; 95% CI, 1.9–3.2) were the major predictors of hospital admission. Two children died, including one without a known pre‐existing medical condition.

          Conclusion: During 2020 and 2021, most SARS‐CoV‐2‐positive children and adolescents who presented to participating hospitals could be managed as outpatients. Outcomes were generally good, including for those admitted to hospital.

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          • 1 Royal Children's Hospital, Melbourne, Melbourne, VIC
          • 2 Murdoch Children's Research Institute, Melbourne, VIC
          • 3 PREDICT Research Network, Melbourne, VIC
          • 4 Western Health, Melbourne, VIC
          • 5 Northern Hospital Epping, Melbourne, VIC
          • 6 The Children's Hospital at Westmead, Sydney, NSW
          • 7 The Children's Hospital at Westmead Clinical School, the University of Sydney, Sydney, NSW
          • 8 John Hunter Hospital, Newcastle, NSW
          • 9 Women's and Children's Hospital, Adelaide, SA
          • 10 Auburn Hospital, Sydney, NSW
          • 11 University of Notre Dame, Sydney, NSW
          • 12 Gold Coast University Hospital, Gold Coast, QLD
          • 13 Child Health Research Centre, the University of Queensland, Brisbane, QLD
          • 14 Queensland Children's Hospital, Brisbane, QLD
          • 15 Eastern Health, Melbourne, VIC
          • 16 Eastern Health Clinical School, Monash University, Melbourne, VIC
          • 17 University Hospital Geelong, Geelong, VIC
          • 18 Austin Hospital, Melbourne, VIC
          • 19 Canberra Hospital, Canberra, ACT
          • 20 Royal Darwin and Palmerston Hospital, Darwin, NT
          • 21 Sunshine Coast University Hospital, Sunshine Coast, QLD
          • 22 Perth Children's Hospital, Perth, WA
          • 23 Curtin University, Perth, WA
          • 24 Royal Hobart Hospital, Hobart, TAS
          • 25 Tasmanian School of Medicine, University of Tasmania, Hobart, TAS
          • 26 The University of Melbourne, Melbourne, VIC


          Correspondence: laila.ibrahim@mcri.edu.au

          Open access:

          Open access publishing facilitated by The University of Melbourne, as part of the Wiley – The University of Melbourne agreement via the Council of Australian University Librarians.

          Acknowledgements: 

          We acknowledge the support of the National Health and Medical Research Council (NHMRC) through a Centre of Research Excellence grant for Paediatric Emergency Medicine (1171228), which also supported Catherine Wilson, who coordinated the study and data collection across the PREDICT network. Franz Babl is supported by an NHMRC Practitioner Fellowship (1124468), which partially supported his role as a senior author and principal investigator for this study.

          We also acknowledge the assistance of the hospital staff who assisted with data retrieval: Katrina Pandey and James Gaston (Sunshine Hospital, Western Health); Deepali Thosar (the Children's Hospital at Westmead); Giles Barrington (Royal Hobart Health Service); Amelia Skaczkowski (Royal Darwin Hospital); Jo Miller, Ethan Fernandes, Andrew McGlinchy, Ye Yang Tham, and Olivia Slifirski (Eastern Health: Box Hill, Maroondah, and Angliss hospitals); Gaby Nieva and Lara Caruso (Adelaide Women's and Children's Hospital); Angus Jones and Alyce Callaghan (Queensland Children's Hospital); and Nitaa Eapen, Yilin Liu, Karen Lu, Violet Sattari Bahri, Michael Wojno, Haoyue Zhang, and Zahra Ataie‐Ashtiani (Royal Children's Hospital).

          Competing interests:

          No relevant disclosures.

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          • 12. Funk AL, Florin TA, Kuppermann N, et al; Pediatric Emergency Research Network‐COVID‐19 Study Team. Outcomes of SARS‐CoV‐2‐positive youths tested in emergency departments: the Global PERN‐COVID‐19 Study. JAMA Netw Open 2022; 5: e2142322.
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            Long COVID in Australia: achieving equitable access to supportive health care

            Tania C Sorrell, Martin Hensher and Lena A Sanci
            Med J Aust 2023; 218 (10): . || doi: 10.5694/mja2.51950
            Published online: 5 June 2023

            Our stressed health system needs innovative solutions to care adequately for people with post‐COVID‐19 conditions

            The post-coronavirus disease 2019 (COVID-19) condition or syndrome (“long COVID”) is defined as the persistence of existing symptoms or the development of new symptoms, without an alternative explanation, three months after an initial acute severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The symptoms, of varying and inconstant severity, can impair everyday functioning. Although long COVID can affect many body systems, the most frequent symptoms are fatigue, shortness of breath, and cognitive dysfunction.1 Long COVID lasting more than twelve weeks is estimated to affect 5–10% of people in Australia who have had COVID-19,2 but lower rates following SARS-CoV-2 infections since 2022 have recently been reported in the United Kingdom (4.0% of first infections in adults, 2.4% of re-infections).3

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            • 1 Sydney Institute for Infectious Diseases, the University of Sydney, Sydney, NSW
            • 2 Menzies Institute for Medical Research, University of Tasmania College of Health and Medicine, Hobart, TAS
            • 3 Melbourne Medical School, the University of Melbourne, Melbourne, VIC


            Correspondence: tania.sorrell@sydney.edu.au
            Acknowledgements: 

            We acknowledge the work of the fellows of the Australian Academy of Health and Medical Sciences and the Australian Academy of Science and of other experts who contributed to a joint written submission to the Parliamentary Inquiry into Long COVID and Repeated COVID Infections and a subsequent roundtable discussion with the Standing Committee on Health, Aged Care and Sport. The final report of the Standing Committee was released on 24 April 2023.13 The Minister for Health and Aged Care, the Hon. Mark Butler MP, subsequently announced that $50 million would be provided from the Medical Research Future Fund for long COVID research.14

            Competing interests:

            Martin Hensher was a member of the National COVID‐19 Health and Research Advisory Committee Working Group on Long COVID (unremunerated). Lena Sanci co‐leads the long COVID project in APPRISE (Australian Partnership for Preparedness Research on Infectious Disease Emergencies, a Centre for Research Excellence. Tania Sorrell is a chief investigator and an executive member of APPRISE, but has received no remuneration in relation to the Long COVID project.

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              Upholding our rights in research: calling for urgent investment in Aboriginal and Torres Strait Islander health research ethics

              Michelle Kennedy and Janine Mohamed
              Med J Aust || doi: 10.5694/mja2.51951
              Published online: 5 June 2023

              Growth in Aboriginal and Torres Strait Islander health research requires urgent investment in Aboriginal and Torres Strait Islander ethical governance

              Indigenous peoples have been conducting research to understand complex systems of knowledge since time immemorial.1 The embodiment of principles aligned with Indigenous ways of knowing, being and doing is central to the legacy of this expert research practice. In this perspective article, we draw on our lived experiences and a review on the field of practice of ethical research.

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              • 1 University of Newcastle, Newcastle, NSW
              • 2 Lowitja Institute, Melbourne, VIC


              Open access

              Open access publishing facilitated by The University of Newcastle, as part of the Wiley ‐ The University of Newcastle agreement via the Council of Australian University Librarians.

              Competing interests:

              No relevant disclosures.

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                Commercial determinants of human rights: for‐profit health care and housing

                Jennifer Lacy‐Nichols, Rebecca Bentley and Adam G Elshaug
                Med J Aust || doi: 10.5694/mja2.51982
                Published online: 5 June 2023

                What do the commercial determinants of health look like for goods and services that are human rights?

                Follow the money. This is the premise driving commercial determinants of health (CDoH) research. Why do children see gambling advertisements when they watch professional sports? Why do vapes have cartoon logos and candy flavours? Why don't we have better implementation of the Framework Convention on Tobacco Control? Why has progress stagnated on the Paris Climate deal? Money, profits and power cut through all these issues.

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                • 1 Centre for Health Policy, University of Melbourne, Melbourne, VIC
                • 2 Menzies Centre for Health Policy and Economics, University of Sydney, Sydney, NSW


                Open access

                Open access publishing facilitated by The University of Melbourne, as part of the Wiley ‐ The University of Melbourne agreement via the Council of Australian University Librarians.

                Competing interests:

                Jennifer Lacy‐Nichols is the recipient of a Fellowship from the Victorian Health Promotion Foundation. Adam Elshaug is Ministerially appointed to the Strengthening Medicare Taskforce and the Medicare Benefits Schedule Review Advisory Committee (MRAC); is health economic and policy advisor to Cancer Australia; is a member of the Research Partnership Advisory Group (translational research priorities 2022–24), Victorian Government Department of Health; is a member of the Victorian Perioperative Learning Health Network Advisory Group (Safer Care Victoria);and holds grants from the National Health and Medical Research Council and the Medical Research Future Fund.

                • 1. Gilmore AB, Fabbri A, Baum F, et al. Defining and conceptualising the commercial determinants of health. Lancet 2023; 401: 1194‐1213.
                • 2. van Schalkwyk MCI, Petticrew M, Cassidy R, et al. A public health approach to gambling regulation: countering powerful influences. Lancet Public Health 2021; 6: e614‐e619.
                • 3. Hyder AA, Werbick M, Scannelli L, Paichadze N. The COVID‐19 pandemic exposes another commercial determinant of health: the global firearm industry. Glob Health Sci Pract 2021; 9: 264‐267.
                • 4. Klein DE, Lima JM. The prison industrial complex as a commercial determinant of health. Am J Public Health 2021; 111: 1750‐1752.
                • 5. Zenone M, Kenworthy N, Maani N. The social media industry as a commercial determinant of health. Int J Health Policy Manag 2022; 12: 6840.
                • 6. Freudenberg N. Lethal but legal: corporations, consumption, and protecting public health. New York: Oxford University Press, 2014.
                • 7. Loewenson R, Godt S, Chanda‐Kapata P. Asserting public health interest in acting on commercial determinants of health in sub‐Saharan Africa: insights from a discourse analysis. BMJ Glob Health 2022; 7: e009271.
                • 8. Schrecker T, Birn AE, Aguilera M. How extractive industries affect health: Political economy underpinnings and pathways. Health Place 2018; 52: 135‐147.
                • 9. Lee K, Freudenberg N, Zenone M, et al. Measuring the commercial determinants of health and disease: a proposed framework. Int J Health Serv 2022; 52: 115‐128.
                • 10. United Nations. Universal Declaration of Human Rights. https://www.un.org/en/about‐us/universal‐declaration‐of‐human‐rights (viewed Feb 2023).
                • 11. Australian Government, Attorney‐General's Department. Right to health: public sector guidance sheet [website]. https://www.ag.gov.au/rights‐and‐protections/human‐rights‐and‐anti‐discrimination/human‐rights‐scrutiny/public‐sector‐guidance‐sheets/right‐health#:~:text=The%20UN%20Committee%20on%20Economic,living%20a%20life%20in%20dignity (viewed Feb 2023).
                • 12. Office of the High Commissioner for Human Rights. Universal Declaration of Human Rights at 70: 30 articles on 30 articles — article 25. United Nations, 2018. https://www.ohchr.org/en/press‐releases/2018/12/universal‐declaration‐human‐rights‐70‐30‐articles‐30‐articles‐article‐25 (viewed Feb 2023).
                • 13. Angell M. The truth about the drug companies: how they deceive us and what to do about it. New York: Random House, 2004.
                • 14. Australian Securities and Investments Commission. Review of buy now pay later arrangements, November 2018. https://download.asic.gov.au/media/4957540/rep600‐published‐07‐dec‐2018.pdf (viewed Feb 2023).
                • 15. Duckett S. Saving private health 2: making private health insurance viable. Melbourne: Grattan Institute, 2019. https://grattan.edu.au/report/saving‐private‐health‐2/ (viewed Apr 2023).
                • 16. Gaynor M. Martin Gaynor testimony “Diagnosing the problem: exploring the effects of consolidation and anticompetitive conduct in health care markets,” House Judiciary Committee [7 Mar 2019]. https://www.govinfo.gov/content/pkg/CHRG‐116hhrg42318/pdf/CHRG‐116hhrg42318.pdf (viewed Feb 2023).
                • 17. Post B, Buchmueller T, Ryan AM. Vertical integration of hospitals and physicians: economic theory and empirical evidence on spending and quality. Med Care Res Rev 2018; 75: 399‐433.
                • 18. Pulok MH, van Gool K, Hall J. The link between out‐of‐pocket costs and inequality in specialist care in Australia. Aust Health Rev 2022; 46: 652‐629.
                • 19. Fisher M, Baum F, Kay A, Friel S. Are changes in Australian national primary healthcare policy likely to promote or impede equity of access? A narrative review. Aust J Prim Health 2017; 23: 209‐215.
                • 20. Erny‐Albrecht K, Bywood P. Corporatisation of general practice — impact and implications. PHCRIS policy issue review. Adelaide: Primary Health Care Research and Information Service, 2016.
                • 21. Bambra C, Gibson M, Sowden A, et al. Tackling the wider social determinants of health and health inequalities: evidence from systematic reviews. J Epidemiol Community Health 2010; 64: 284‐291.
                • 22. Urban Reform Institute, Frontier Centre for Public Policy. International housing affordability. Demographia, 2023. http://www.demographia.com/dhi.pdf (viewed Apr 2023).
                • 23. Bentley R, Baker E, Ronald R, et al. Housing affordability and mental health: an analysis of generational change. Housing Studies 2022; 37: 1842‐1857.
                • 24. Pawson H, Lilley D. Managing access to social housing in Australia: unpacking policy frameworks and service provision outcomes. Sydney: UNSW City Futures Research Centre, 2022.
                • 25. Mishra SR, Wilson T, Andrabi H, et al. The total health gains and cost savings of eradicating cold housing in Australia. Soc Sci Med 2023; doi:https://doi.org/10.1016/j.socscimed.2023.115954.
                • 26. Wynne L, Ruming K, Shrestha P, Rogers D. The marketisation of social housing in New South Wales. In: Meagher G, Stebbing A, Perche D; editors. Designing social service markets. Canberra: ANU Press; 2022.
                • 27. Australian Bureau of Statistics. December quarter 2022, Total value of dwellings. ABS, 2022. https://www.abs.gov.au/statistics/economy/price‐indexes‐and‐inflation/total‐value‐dwellings/latest‐release (viewed Feb 2023).
                • 28. Gurran N, Phibbs P. How the Property Council is shaping the debate around negative gearing, taxes. The Conversation 2016; 17 June. https://theconversation.com/how‐the‐property‐council‐is‐shaping‐the‐debate‐around‐negative‐gearing‐taxes‐61006 (viewed May 2023).
                • 29. Property Council of Australia. New Victorian apartment design guidelines [website]. Property Council of Australia, 2021. https://www.propertycouncil.com.au/news/new‐victorian‐apartment‐design‐guidelines (viewed May 2023).
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                • 31. Manahan MA, Kumar M. The great takeover: mapping of multistakeholderism in global governance. Amsterdam: Transnational Institute, 2022. https://www.tni.org/en/publication/the‐great‐takeover (viewed Feb 2023).
                • 32. Lacy‐Nichols J, Nandi S, Mialon M, et al. Conceptualising commercial entities in public health: beyond unhealthy commodities and transnational corporations. Lancet 2023; 401: 1214‐1228.

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                  The impact on poisonings of up‐scheduling of modified release paracetamol to Schedule 3 (pharmacist only medicine)

                  Rose Cairns, Firouzeh Noghrehchi and Nicholas A Buckley
                  Med J Aust 2023; 218 (9): . || doi: 10.5694/mja2.51888
                  Published online: 15 May 2023

                  In Australia, paracetamol is the agent most frequently implicated in drug overdoses, and their frequency is increasing, particularly in young people.1 Paracetamol overdose causes significant morbidity despite treatment, and is the leading cause of acute liver failure in Western countries.2 Modified release (MR) paracetamol overdose is associated with a higher rate of liver injury than immediate release paracetamol.3 The sole therapeutic benefit of MR paracetamol is its more convenient dosage regimen (three rather than four times a day).4

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                  • 1 The University of Sydney, Sydney, NSW
                  • 2 NSW Poisons Information Centre, Children's Hospital at Westmead, Sydney, NSW


                  Open access

                  Open access publishing facilitated by The University of Sydney, as part of the Wiley – The University of Sydney agreement via the Council of Australian University Librarians.

                  Acknowledgements: 

                  Rose Cairns is supported by a National Health and Medical Research Council (NHMRC) Investigator Grant (1196516); Nicholas Buckley is supported by an NHMRC investigator Grant (2007726). We thank the staff of the New South Wales Poisons Information Centre for collecting the data analysed in our study.

                  Competing interests:

                  Rose Cairns holds an untied educational grant from Reckitt; this funder had no role in this study.

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                    Comparison of performance outcomes after general practice training in remote and rural or regional locations in Australia

                    Emily Anderson, Matthew R McGrail, Aaron Hollins, Louise Young, Lawrie McArthur, Belinda O'Sullivan and Tiana Gurney
                    Med J Aust 2023; 218 (9): . || doi: 10.5694/mja2.51930
                    Published online: 15 May 2023

                    General practice training is provided in geographically diverse locations across Australia to promote the development of the rural and remote medical workforce. Training in rural and remote locations supports learning locally required types of medical practice and builds both social and professional connections that increase the likelihood of trainees later practising in these communities.1,2 The remote learning model appears to be successful,3 but a 2020 scoping review found only limited evidence for the equivalence of learning outcomes after training in remote or less remote locations.4 We therefore compared formative assessment outcomes for general practice trainees in remote locations with those of trainees in rural or regional locations.

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                    • 1 James Cook University, Townsville, QLD
                    • 2 Rural Clinical School, University of Queensland, Rockhampton, QLD
                    • 3 Rural Clinical School, University of Queensland, Toowoomba, QLD


                    Correspondence: emma.anderson1@jcu.edu.au

                    Open access

                    Open access publishing facilitated by James Cook University, as part of the Wiley – James Cook University agreement via the Council of Australian University Librarians.

                    Acknowledgements: 

                    This project was funded by an Education Research Grant from the Australian College of Rural and Remote Medicine (salaries and research costs).

                    Competing interests:

                    No relevant disclosures.

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                      The diagnosis and initial management of melanoma in Australia: findings from the prospective, population‐based QSkin study

                      Nirmala Pandeya, Catherine M Olsen, Maja M Shalit, Jean Claude Dusingize, Rachel E Neale and David C Whiteman
                      Med J Aust 2023; 218 (9): . || doi: 10.5694/mja2.51919
                      Published online: 15 May 2023

                      Abstract

                      Objectives: To determine the proportions of newly diagnosed melanomas treated by different medical specialist types, to describe the types of excisions performed, and to investigate factors associated with treating practitioner specialty and excision type.

                      Design, setting: Prospective cohort study; analysis of linked data: baseline surveys, hospital, pathology, Queensland Cancer Register, and Medical Benefits Schedule databases.

                      Participants: Random sample of 43 764 Queensland residents aged 40–69 years recruited during 2011, with initial diagnoses of in situ or invasive melanoma diagnosed to 31 December 2019.

                      Main outcome measures: Treating practitioner type and treatment modality for first incident melanoma; second and subsequent treatment events for the primary melanoma.

                      Results: During a median follow‐up of 8.4 years (interquartile range, 8.3–8.8 years), 1683 eligible participants (720 women, 963 men) developed at least one primary melanoma (in situ melanoma, 1125; invasive melanoma, 558), 1296 of which (77.1%) were initially managed in primary care; 248 were diagnosed by dermatologists (14.8%), 83 by plastic surgeons (4.9%), 43 by general surgeons (2.6%), and ten by other specialists (0.6%). The most frequent initial procedures leading to histologically confirmed melanoma diagnosis were first excision (854, 50.7%), shave biopsy (549, 32.6%), and punch biopsy (178, 10.6%); 1339 melanomas (79.6%) required two procedures, 187 (11.1%) three. Larger proportions of melanomas diagnosed by dermatologists (87%) or plastic surgeons (71%) were in people living in urban areas than of those diagnosed in primary care (63%); larger proportions of melanomas diagnosed by dermatologists or plastic surgeons than of those diagnosed in primary care were in people with university degrees (45%, 42% v 23%) or upper quartile clinical risk scores (63%, 59% v 47%).

                      Conclusions: Most incident melanomas in Queensland are diagnosed in primary care, and nearly half are initially managed by partial excision (shave or punch biopsy). Second or third, wider excisions are undertaken in about 90% of cases.

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                      • QIMR Berghofer Medical Research Institute, Brisbane, QLD


                      Open access

                      Open access publishing facilitated by The University of Queensland, as part of the Wiley – The University of Queensland agreement via the Council of Australian University Librarians.

                      Acknowledgements: 

                      This study was supported by the National Health and Medical Research Council (NHMRC; APP1073898; APP1063061; APP1185416). David Whiteman is supported by an NHMRC Research Fellowship (APP11554130). The funders played no role in the design, execution, analysis or interpretation of this study. We thank Cancer Alliance Queensland who maintain the Queensland Cancer Register for their valuable contributions to this study.

                      Competing interests:

                      No relevant disclosures.

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                      • 2. Gordon LG, Leung W, Johns R, et al. Estimated healthcare costs of melanoma and keratinocyte skin cancers in Australia and Aotearoa New Zealand in 2021. Int J Res Public Health 2022; 19: 3178.
                      • 3. Australian Institute of Health and Welfare. Risk of melanoma of the skin by age and over time. In: Cancer data in Australia. Updated 4 Oct 2020. https://www.aihw.gov.au/reports/cancer/cancer‐data‐in‐australia/contents/cancer‐data‐commentaries/risk‐of‐melanoma‐of‐the‐skin‐by‐age‐and‐over‐time (viewed Dec 2022).
                      • 4. Thompson BS, Pandeya N, Olsen CM, et al. Keratinocyte cancer excisions in Australia: who performs them and associated costs. Australas J Dermatol 2019; 60: 294‐300.
                      • 5. Hollestein L, Weinstock M, Le Roux E, Olsen C. More than many: how to manage the most frequent cancer? J Invest Dermatol 2017; 137: 1823‐1826.
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                      • 20. Hay J, Keir J, Jimenez Balcells C, et al. Characteristics, treatment and outcomes of 589 melanoma patients documented by 27 general practitioners on the Skin Cancer Audit Research Database. Australas J Dermatol 2022; 63: 204‐212.
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                      • 24. Olsen CM, Wilson LF, Green AC, et al. Cancers in Australia attributable to exposure to solar ultraviolet radiation and prevented by regular sunscreen use. Aust N Z J Public Health 2015; 39: 471‐476.

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