Topics

The associated risks, particularly that of long term use, are underestimated, and appropriate measures are needed

Before 1990, opioids were primarily used to treat severe acute and cancer pain. In the subsequent 30 years, opioids have been increasingly used for treating chronic non‐malignant pain; prescribing has increased exponentially in the developed world, particularly in the United States, but also in Canada and Australia.1 Regrettably, this has not only resulted in poor outcomes for patients living with chronic pain; the analgesic efficacy of opioids for this indication are limited, and they do not improve, and often reduce, function and quality of life.2 Further, diversion of prescribed opioids and their misuse have risen in parallel with increased prescribing, leading to higher numbers of overdoses deaths. In Australia, about 1100 people died following opioid overdoses during 2018, and 75% of cases involved prescription opioids (similar to the number of deaths from car accidents in that year).3

University of Western Australia, Perth, WA

Correspondence: stephan.schug@uwa.edu.au

Competing interests:

The Anaesthesiology Unit of the University of Western Australia and Stephan Schug personally (since his retirement in October 2019) have received research and travel funding and speaking and consulting honoraria from Grünenthal, Indivior, Mundipharma, Pfizer, iX Biopharma, Seqirus, Xgene, Biogen, Luye Pharma and Foundry during the past 36 months.

1. Häuser W, Schug S, Furlan AD. The opioid epidemic and national guidelines for opioid therapy for chronic noncancer pain: a perspective from different continents. Pain Rep 2017; 2: e599.
2. Busse JW, Wang L, Kamaleldin M, et al. Opioids for chronic noncancer pain: a systematic review and meta‐analysis. JAMA 2018; 320: 2448–2460.
3. Man N, Chrzanowska A, Dobbins T, et al. Trends in drug‐induced deaths in Australia, 1997–2018 (Drug Trends Bulletin Series). Sydney: National Drug and Alcohol Research Centre, UNSW Sydney, 2019. https://ndarc.med.unsw.edu.au/resource/trends-drug-induced-deaths-australia-1997-2018 (viewed Sept 2020).
4. Roughead EE, Lim R, Ramsay E, et al. Persistence with opioids post discharge from hospitalisation for surgery in Australian adults: a retrospective cohort study. BMJ Open 2019; 9: e023990.
5. Schug SA, Palmer GM, Scott DA, et al, editors. Acute pain management: scientific evidence. 4th edition. Melbourne: Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine, 2015; here: pp. 365–368.
6. Macintyre PE, Huxtable CA, Flint SL, Dobbin MD. Costs and consequences: a review of discharge opioid prescribing for ongoing management of acute pain. Anaesth Intensive Care 2014; 42: 558–574.
7. Stewart JE, Tuffin PH, Kay J, et al. The effect of guideline implementation on discharge analgesia prescribing (two years on). Anaesth Intensive Care 2019; 47: 40–44.
8. McAnally H. Rationale for and approach to preoperative opioid weaning: a preoperative optimization protocol. Perioper Med (Lond) 2017; 6: 19.
9. Stark N, Kerr S, Stevens J. Prevalence and predictors of persistent post‐surgical opioid use: a prospective observational cohort study. Anaesth Intensive Care 2017; 45: 700–706.
10. Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long‐term opioid use: United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017; 66: 265–269.
11. Australian and New Zealand College of Anaesthetists, Faculty of Pain Medicine. Position statement on the use of slow‐release opioid preparations in the treatment of acute pain. Mar 2018. https://www.anzca.edu.au/getattachment/d9e2a7c5-0f17-42d3-bda7-c6dae7e55ced/Position-statement-on-the-use-of-slow-release-opioid-preparations-in-the-treatmentofacute-pain (viewed Oct 2020).
12. Brat GA, Agniel D, Beam A, et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study. BMJ 2018; 360: j5790.
13. Therapeutic Goods Administration. Return your unused opioids: resource kit. July 2019. https://www.tga.gov.au/publication/return-your-unused-opioids-resource-kit (viewed Sept 2020).
14. Hopkins R, Bui T, Konstantatos AH, et al. Educating junior doctors and pharmacists to reduce discharge prescribing of opioids for surgical patients: a cluster randomised controlled trial. Med J Aust 2020; 213: 417–423.
15. Stevens J, Trimboli A, Samios P, et al. A sustainable method to reduce postoperative oxycodone discharge prescribing in a metropolitan tertiary referral hospital. Anaesthesia 2019; 74: 292–299.
16. Allen ML, Leslie K, Parker AV, et al. Post‐surgical opioid stewardship programs across Australia and New Zealand: current situation and future directions. Anaesth Intensive Care 2019; 47: 548–552.

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Medical education
Snapshot

Yellow nails syndrome: complete triad

Adrián López Alba and Agustín Blanco Echevarría

Med J Aust 2020; 213 (9): . || doi: 10.5694/mja2.50807
Published online: 2 November 2020

Topics

Respiratory tract diseases

Hematologic diseases

Health occupations

An 83‐year‐old male non‐smoker presented with chronic purulent cough. On physical examination, xanthonychia (yellow discoloration), onychauxis (thickened nails), onycholisis (separation of the nail from the nail bed), enhanced transverse curvature, and scleronychia (hardening and thickening of the nails) were observed (Figure, A). He had a 5 year history of decreased longitudinal nail growth and progressive adult onset bilateral lower limb lymphoedema. Findings on computed tomography scan demonstrated severe bilateral cystic bronchiectasis (Figure, B and C). Yellow nails syndrome is a disorder characterised by the triad of yellow thickened nails, lymphoedema and respiratory manifestations, typically chronic cough, bronchiectasis or pleural effusion. All three features appear in only 27–60% of patients.1 Treatment is symptomatic and includes antibiotic prescription for bronchiectasis and oral vitamin E alone or combined with triazole antifungals for yellow nails, achieving partial to complete responses.1

Hospital Universitario 12 de Octubre, Madrid, Spain

Correspondence: alalba@salud.madrid.org

Acknowledgements:

We thank the patient who made the article possible.

Competing interests:

No relevant disclosures.

1. Vignes S, Baran R. Yellow nail syndrome: a review. Orphanet J Rare Dis 2017; 12: 42.

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Meta‐analysis

Gut microbiota‐derived trimethylamine N‐oxide is associated with poor prognosis in patients with heart failure

Wensheng Li, Anqing Huang, Hailan Zhu, Xinyue Liu, Xiaohui Huang, Yan Huang, Xiaoyan Cai, Jianhua Lu and Yuli Huang

Med J Aust 2020; 213 (8): . || doi: 10.5694/mja2.50781
Published online: 19 October 2020

Topics

Cardiovascular diseases

Diagnostic techniques and procedures

Abstract

Objective: Gut microbiota‐produced trimethylamine N‐oxide (TMAO) is a risk factor for cardiovascular events. However, conflicting findings regarding the link between plasma TMAO level and prognosis for patients with heart failure have been reported. We examined the association of plasma TMAO concentration with risk of major adverse cardiac events (MACEs) and all‐cause mortality in patients with heart failure.

Study design: Meta‐analysis of prospective clinical studies.

Data sources: We searched electronic databases (PubMed, EMBASE) for published prospective studies examining associations between plasma TMAO level and MACEs and all‐cause mortality in adults with heart failure.

Data synthesis: Hazard ratios (HRs) with 95% confidence intervals for associations between TMAO level and outcomes were estimated in random effects models. In seven eligible studies including a total of 6879 patients (median follow‐up, 5.0 years) and adjusted for multiple risk factors, higher plasma TMAO level was associated with greater risks of MACEs (TMAO tertile 3 v tertile 1: HR, 1.68; 95% CI, 1.44–1.96; per SD increment: HR, 1.26; 95% CI, 1.18–1.36) and of all‐cause mortality (TMAO tertile 3 v tertile 1: HR, 1.67; 95% CI, 1.17–2.38; per SD increment: HR, 1.26; 95% CI, 1.07–1.48). Higher TMAO level was also associated with greater risk of MACEs after adjusting for estimated glomerular filtration rate (eGFR; six studies included); however, the heterogeneity of studies in which risk was adjusted for eGFR was significant (I² = 76%).

Conclusions: Elevated plasma TMAO level in patients with heart failure is associated with poorer prognoses. This association is only partially mediated by renal dysfunction.

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1 Shunde Hospital of Southern Medical University, Foshan (Guangdong), China
2 George Institute for Global Health, Sydney, NSW

Correspondence: yhuang@georgeinstitute.org.au

Acknowledgements:

Our investigation was supported by the Science and Technology Innovation Project in Foshan, Guangdong (FS0AA‐KJ218‐1301‐0006), the Clinical Research Startup Program of Shunde Hospital, Southern Medical University (CRSP2019001, CRSP2019008), the self‐financing Science and Technology Plan Project of Foshan, Guangdong (Medical Science and Technology Research Key Project; 2018AB00208), and the Medical Science and Technology Research Foundation of Guangdong Province (A2018209).We thank Julia Jenkins (Liwen Bianji, Edanz Editing China; www.liwenbianji.cn/ac), for editing the English text of our manuscript.

Competing interests:

No relevant disclosures.

1. Ziaeian B, Fonarow GC. Epidemiology and aetiology of heart failure. Nat Rev Cardiol 2016; 13: 368–378.
2. Benjamin EJ, Muntner P, Alonso A, et al. American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics: 2019 update. A report from the American Heart Association. Circulation 2019; 139: e56–e528.
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29. Livshits G, Kalinkovich A. Inflammaging as a common ground for the development and maintenance of sarcopenia, obesity, cardiomyopathy and dysbiosis. Ageing Res Rev 2019; 56: 100980.
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32. Makrecka‐Kuka M, Volska K, Antone U, et al. Trimethylamine N‐oxide impairs pyruvate and fatty acid oxidation in cardiac mitochondria. Toxicol Lett 2017; 267: 32–38.
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Editorials

“No jab, no pay” pays off

Terence M Nolan

Med J Aust 2020; 213 (8): . || doi: 10.5694/mja2.50796
Published online: 19 October 2020

Topics

Environment and public health

Pediatric medicine

The policy has been effective, albeit with modest closure of coverage gaps, and without substantial backlash

In April 1998, the Australian government linked the payment of childcare subsidies (Childcare Assistance and Childcare Cash Rebate) and the Maternity Immunisation Allowance to childhood vaccination status.1 To receive these benefits, families needed to show that their child was fully vaccinated according to the National Immunisation Program Schedule.2 Further, the Victorian government passed legislation in 2015 that required childcare proprietors to record and regularly update the vaccination status of each child in their care, and to restrict admission to children who were up to date (“No jab, no play”).3 Other states have since followed suit.

1 Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC
2 Murdoch Children's Research Institute, Melbourne, VIC

Correspondence: t.nolan@unimelb.edu.au

Competing interests:

No relevant disclosures.

1. Bond L, Nolan T, Lester R. Immunisation uptake, services required and government incentives for users of formal day care. Aust N Z J Public Health 1999; 23: 368–376.
2. Bond L, Davie G, Carlin JB, et al. Increases in vaccination coverage for children in child care, 1997 to 2000: an evaluation of the impact of government incentives and initiatives. Aust N Z J Public Health 2002; 26: 58–64.
3. Department of Health and Human Services (Victoria). No jab no play [website]. 2017. https://www2.health.vic.gov.au/public-health/immunisation/vaccination-children/no-jab-no-play (viewed Sept 2020).
4. Lawrence GL, MacIntyre CR, Hull BP, McIntyre PB. Effectiveness of the linkage of child care and maternity payments to childhood immunisation. Vaccine 2004; 22: 2345–2350.
5. Hull BP, Beard FH, Hendry AJ, et al. “No jab, no pay”: catch‐up vaccination activity during its first two years. Med J Aust 2020; 213: 364–369.
6. Leask J, Danchin M. Imposing penalties for vaccine rejection requires strong scrutiny. J Paediatr Child Health 2017; 53: 439–444.

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Editorials

Time for a new approach to funding residential aged care

Edward Strivens

Med J Aust 2020; 213 (8): . || doi: 10.5694/mja2.50799
Published online: 19 October 2020

Topics

Health services administration

Gerontology

Support should be tied to the health care needs of residents, not to how eligibility for subsidies is assessed

Government support for residential aged care facilities (RACFs) in Australia has undergone major periodic shifts in the attempt to match residents’ needs and the costs of care. The money involved is considerable: during 2018–19, the Australian government provided $13.3 billion in subsidies, with more than 200 000 people living in RACFs.1

1 James Cook University, Cairns, QLD
2 Cairns and Hinterland Hospital and Health Service, Cairns, QLD

Correspondence: Edward.Strivens@health.qld.gov.au

Competing interests:

No relevant disclosures.

1. Australian Institute of Health and Welfare. Government spending on aged care. Updated Apr 2020. https://www.gen-agedcaredata.gov.au/Topics/Government-spending-on-aged-care (viewed Sept 2020).
2. Rowe L. Preventing a COVID‐19 firestorm in residential aged care. Insight+ [online], 4 May 2020. https://insightplus.mja.com.au/2020/17/preventing-a-covid-19-firestorm-in-residential-aged-care (viewed Sept 2020).
3. Australian Institute of Health and Welfare. GEN data: People leaving aged care. June 2019. https://www.gen-agedcaredata.gov.au/Resources/Access-data/2018/June/GEN-data-People-leaving-aged-care (viewed Sept 2020).
4. Royal Commission into Aged Care Quality and Safety. Interim report, volume 1: neglect. Oct 2019. https://agedcare.royalcommission.gov.au/sites/default/files/2020-02/interim-report-volume-1.pdf (viewed Sept 2020).
5. Australian Department of Health. The Aged Care Funding Instrument (ACFI). Updated Apr 2020. https://www.health.gov.au/initiatives-and-programs/residential-aged-care/funding-for-residential-aged-care/the-aged-care-funding-instrument-acfi (viewed Sept 2020).
6. McNamee J, Poulos C, Seraji H, et al. Alternative aged care assessment, classification system and funding models: final report, volume one. Wollongong: Centre for Health Service Development, Australian Health Services Research Institute, University of Wollongong, 2017. https://www.health.gov.au/resources/publications/alternative-aged-care-assessment-classification-system-and-funding-models-report (viewed Sept 2020).
7. Eagar K, Gordon R, Snoek MF, et al. The Australian National Aged Care Classification (AN‐ACC): a new casemix classification for residential aged care. Med J Aust 2020; 213: 359–363.
8. Johnson Village Services. The case for a fixed funding model (Consultation Paper 1 submissions, WF.660.00076.003). Feb 2020. https://agedcare.royalcommission.gov.au/media/26741 (viewed Sept 2020).
9. Ratcliffe J, Chen G, Cleland J, et al; Caring Futures Institute (Flinders University). Australia's aged care system: assessing the views and preferences of the general public for quality of care and future funding (Royal Commission into Aged Care Quality and Safety, research paper 6). July 2020. https://agedcare.royalcommission.gov.au/sites/default/files/2020-07/research_paper_6_-_australias_aged_care_system_-_assessing_the_views_an._.pdf (viewed Sept 2020).

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Perspectives

Considerations for cancer immunotherapy during the COVID‐19 pandemic

Yada Kanjanapan and Desmond Yip

Med J Aust 2020; 213 (9): . || doi: 10.5694/mja2.50805
Published online: 14 October 2020

Correction(s) for this article:

Erratum | Published online: 19 September 2025

Topics

Infectious diseases

Immune system diseases

Neoplasms

Cancer immunotherapy during the COVID‐19 pandemic presents management challenges from immune‐related toxicities, requiring careful patient selection

The coronavirus disease 2019 (COVID‐19) pandemic has led to fundamental re‐evaluation of the benefits versus risks of treatment in oncology. Immunotherapy has had an expanding presence in oncology, becoming a primary systemic treatment option in diseases such as melanoma, lung, urothelial, renal, and head and neck cancers. Immune checkpoint inhibitor (ICI) therapy, namely anti‐programmed cell death protein 1 (anti‐PD‐1), anti‐programmed cell death ligand 1 (anti‐PD‐L1) and anti‐cytotoxic T‐lymphocyte‐associated protein 4 (anti‐CTLA‐4) antibodies, halt the negative regulatory checks of T lymphocytes, thus activating the immune response against tumours. Patients with cancer receiving these treatments are faced with a unique set of treatment‐related toxicities driven by an autoimmune mechanism.

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1 Canberra Hospital, Canberra, ACT
2 Australian National University, Canberra, ACT

Correspondence: yada.kanjanapan@act.gov.au

Competing interests:

No relevant disclosures.

1. Bersanelli M. Controversies about COVID‐19 and anticancer treatment with immune checkpoint inhibitors. Immunotherapy 2020; 12: 269–273.
2. Dai M, Liu D, Liu M, et al. Patients with cancer appear more vulnerable to SARS‐COV-2: a multicenter study during the COVID‐19 outbreak. Cancer Discov 2020; 10: 783–791.
3. Qin C, Zhou L, Hu Z, et al. Dysregulation of immune response in patients with COVID‐19 in Wuhan, China. Clin Infect Dis 2020; 71: 762–768.
4. Lim SY, Lee JH, Gide TN, et al. Circulating cytokines predict immune‐related toxicity in melanoma patients receiving anti‐PD‐1-based immunotherapy. Clin Cancer Res 2019; 25: 1557–1563.
5. Robilotti EV, Babady NE, Mead PA, et al. Determinants of COVID‐19 disease severity in patients with cancer. Nat Med 2020; 26: 1218–1223.
6. Garassino MC, Whisenant JG, Huang LC, et al. COVID‐19 in patients with thoracic malignancies (TERAVOLT): first results of an international, registry‐based, cohort study. Lancet Oncol 2020; 21: 914–922.
7. Wolchok JD, Rollin L, Larkin J. Nivolumab and ipilimumab in advanced melanoma. N Engl J Med 2017; 377: 2503–2504.
8. Motzer RJ, Tannir NM, McDermott DF, et al. Nivolumab plus ipilimumab versus sunitinib in advanced renal‐cell carcinoma. N Engl J Med 2018; 378: 1277–1290.
9. RECOVERY Collaborative Group. Dexamethasone in hospitalized patients with COVID‐19 — preliminary report. N Engl J Med 2020; https://doi.org/10.1056/nejmoa2021436 [Epub ahead of print].
10. Del Castillo M, Romero FA, Argüello E, et al. The spectrum of serious infections among patients receiving immune checkpoint blockade for the treatment of melanoma. Clin Infect Dis 2016; 63: 1490–1493.
11. Schwarz M, Kocher F, Niedersuess‐Beke D, et al. Immunosuppression for immune checkpoint‐related toxicity can cause Pneumocystis jirovecii pneumonia (PJP) in Non‐small‐cell lung cancer (NSCLC): a report of 2 cases. Clin Lung Cancer 2019; 20: e247–e250.
12. Fujita K, Kim YH, Kanai O, et al. Emerging concerns of infectious diseases in lung cancer patients receiving immune checkpoint inhibitor therapy. Respir Med 2019; 146: 66–70.
13. Picchi H, Mateus C, Chouaid C, et al. Infectious complications associated with the use of immune checkpoint inhibitors in oncology: reactivation of tuberculosis after anti PD‐1 treatment. Clin Microbiol Infect 2018; 24: 216–218.
14. Läubli H, Balmelli C, Kaufmann L, et al. Influenza vaccination of cancer patients during PD‐1 blockade induces serological protection but may raise the risk for immune‐related adverse events. J Immunother Cancer 2018; 6: 40.
15. Failing JJ, Ho TP, Yadav S, et al. Safety of influenza vaccine in patients with cancer receiving pembrolizumab. JCO Oncol Pract 2020; 16: e573–e580.
16. Segelov E, Underhill C, Prenen H, et al. Practical considerations for treating patients with cancer in the COVID‐19 pandemic. JCO Oncol Pract 2020; 16: 467–482.
17. Weinkove R, McQuilten ZK, Adler J, et al. Managing haematology and oncology patients during the COVID‐19 pandemic: interim consensus guidance. Med J Aust 2020; 212: 481–489. https://www.mja.com.au/journal/2020/212/10/managing-haematology-and-oncology-patients-during-covid-19-pandemic-interim-0
18. Friedlaender A, Kim C, Addeo A. Rethinking the optimal duration of immune checkpoint inhibitors in non‐small cell lung cancer throughout the COVID‐19 pandemic. Front Oncol 2020; 10: 862.
19. Robert C, Ribas A, Hamid O, et al. Durable Complete Response After Discontinuation of Pembrolizumab in Patients With Metastatic Melanoma. J Clin Oncol 2018; 36: 1668–1674.

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Perspectives

Demographics and performance of candidates in the examinations of the Australian Medical Council, 1978–2019

Neville D Yeomans, Jillian R Sewell, Philip Pigou and Stuart Macintyre

Med J Aust 2021; 214 (2): . || doi: 10.5694/mja2.50800
Published online: 5 October 2020

Topics

Environment and public health

Medical education

Health services administration

Australia has relied, for most of its history, on international medical graduates (IMGs) to supplement its workforce. Since 1978, IMGs applying for general registration to practise in Australia have usually needed to pass the examinations of the Australian Medical Examining Council, or since 1986, its successor, the Australian Medical Council (AMC). The AMC provides several pathways to registration by the Australian Health Practitioner Regulation Agency (AHPRA). The route now termed “the standard pathway” consists of a two‐part assessment including a multiple choice question (MCQ) examination followed by a clinical examination. While most IMGs are required to pass both examinations, since 2007, IMGs who qualified in the so‐called competent authority countries (the United Kingdom, Ireland, the United States and Canada) have usually not been required to sit these examinations.1

1 University of Melbourne, Melbourne, VIC
2 Centre for Community Child Health, Melbourne, VIC
3 Australian Medical Council, Canberra, ACT

Correspondence: nyeomans@unimelb.edu.au

Acknowledgements:

We acknowledge the assistance of Kevin Ng and Prathyusha Sama, Senior Computer Programmer and Software Developer at the AMC, for programming to extract the de‐identified data analysed in this article.

Competing interests:

No relevant disclosures.

1. Medical Board of Australia. Competent authority pathway [website]. AHPRA, 2019. https://www.medicalboard.gov.au/Registration/International-Medical-Graduates/Competent-Authority-Pathway.aspx (viewed July 2020).
2. Australian Government Publishing Service. Human Rights and Equal Opportunity Commission — annual report 1990–91. Canberra: Commonwealth of Australia; 1991. https://humanrights.gov.au/sites/default/files/Annual_Report_90-91.pdf (viewed July 2020).
3. Australian Competition and Consumer Commission and Australian Health Workforce Officials’ Committee. Review of Australian specialist medical colleges: report to Australian Health Ministers. Canberra: Commonwealth of Australia, 2005.
4. House of Representatives Standing Committee on Health and Ageing. Lost in the labyrinth: report on the inquiry into registration processes and support for overseas trained doctors. Canberra: Commonwealth of Australia, 2012. https://www.aph.gov.au/Parliamentary_Business/Committees/House_of_Representatives_Committees?url=haa/overseasdoctors/report.htm (viewed July 2020).
5. Geffen L. Assuring medical standards: the Australian Medical Council 1985–2010. Canberra, ACT: Australian Medical Council, 2010.
6. Australian Medical Council Limited. IMG guides. https://www.amc.org.au/publications/img-guides/ (viewed July 2020).
7. United Nations Statistics Division. Geographical regions 1999. https://unstats.un.org/unsd/methodology/m49 (viewed July 2020).
8. Australian Bureau of Statistics. Migration, Australia, 1993–2018 [Cat. No. 3412.0]. Canberra, ACT: ABS, 2018. https://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/3412.02017-18?OpenDocument (viewed July 2020).
9. Breen K, Frank I, Walters T. Australian Medical Council: a view from the inside. Intern Med J 2001; 31: 243–248.
10. McCoubrie P. Improving the fairness of multiple‐choice questions: a literature review. Med Teach 2004; 26: 709–712.
11. Yeomans ND. They came to heal: Australia's medical immigrants, 1960 to the present [dissertation]. Melbourne: University of Melbourne, 2018: 120.
12. Dewhurst NG, McManus C, Mollon J, et al. Performance in the MRCP (UK) examination 2003–4: analysis of pass rates of UK graduates in relation to self‐declared ethnicity and gender. BMC Med 2007; 5: 8.
13. Shellito JL, Osland JS, Helmer SD, Chang FC. American Board of Surgery examinations: can we identify surgery residency applicants and residents who will pass the examinations on the first attempt? Am J Surg 2010; 199: 216–222.
14. Rubright JD, Jodoin M, Barone MA. Examining demographics, prior academic performance, and United States Medical Licensing Examination scores. Acad Med 2019; 94: 364–370.
15. Unwin E, Potts HWW, Dacre J, et al. Passing MRCP (UK) PACES: a cross‐sectional study examining the performance of doctors by sex and country. BMC Med Educ 2018; 18: 1–9.
16. Sandhu H, Adams A, Singleton L, et al. The impact of gender dyads on doctor–patient communication: A systematic review. Patient Educ Couns 2009; 76: 348–355.
17. Menzies L, Minson S, Brightwell A, et al. An evaluation of demographic factors affecting performance in a paediatric membership multiple‐choice examination. Postgrad Med J 2015; 91: 72–76.
18. Lipner R, Song H, Biester T, et al. Factors that influence general internists’ and surgeons’ performance on maintenance of certification exams. Acad Med 2011; 86: 53–58.
19. McGrail MR, Russell DJ. Australia's rural medical workforce: supply from its medical schools against career stage, gender and rural‐origin. Aust J Rural Health 2016; 25: 298–305.

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Research letter

Implementing cardiovascular disease preventive care guidelines in general practice: an opportunity missed

Charlotte M Hespe, Anna Campain, Ruth Webster, Anushka Patel, Lucie Rychetnik, Mark F Harris and David P Peiris

Med J Aust 2020; 213 (7): . || doi: 10.5694/mja2.50756
Published online: 5 October 2020

Topics

Cardiovascular diseases

Health services administration

General medicine

Cardiovascular disease (CVD) is the leading cause of death in Australia.1 New treatment guidelines based on absolute CVD risk estimates were adopted in 2012.2 General practitioners are central to implementing these guidelines, as about 90% of people in Australia consult GPs each year,3 but large evidence–practice gaps in the management of people with CVD in general practice have been reported.4

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1 The University of Notre Dame Australia, Sydney, NSW
2 The George Institute for Global Health, Sydney, NSW
3 University of New South Wales, Sydney, NSW
4 The Australian Health Prevention Partnership, Sax Institute, Sydney, NSW
5 Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW
6 Office of the Chief Scientist, The George Institute for Global Health, Sydney, NSW

Correspondence: charlotte.hespe@nd.edu.au

Acknowledgements:

The University of Notre Dame received a Bupa Health Foundation grant for research into cardiovascular disease and diabetes that funded the Q Pulse study and a quality improvement project in 46 practices in the Central and Eastern Sydney Primary Health Network. Ruth Webster is supported by a National Health and Medical Research Council (NHMRC) Early Career Fellowship (APP1125044), Anushka Patel by an NHMRC Principal Research Fellowship (APP1136898), and David Peiris by a Heart Foundation Future Leader Fellowship (101890) and NHMRC Career Development Fellowship (APP1143904).

Competing interests:

George Health Enterprises, the social enterprise arm of the George Institute for Global Health, has received funding for the development of fixed dose combination therapy, and has commercial relationships involving digital innovations similar to the interventions in the INTEGRATE study.

1. Australian Institute of Health and Welfare. Deaths in Australia. Updated 6 Aug 2020. https://www.aihw.gov.au/reports/life-expectancy-death/deaths-in-australia/contents/leading-causes-of-death (viewed Aug 2020).
2. National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk. Apr 2012. http://www.cvdcheck.org.au/pdf/Absolute_CVD_Risk_Full_Guidelines.pdf (viewed May 2020).
3. Royal Australian College of General Practitioners. General practice: health of the nation 2018. Sept 2018. https://www.racgp.org.au/download/Documents/Publications/Health-of-the-Nation-2018-Report.pdf (viewed Aug 2020).
4. Webster RJ, Heeley EL, Peiris DP, et al. Gaps in cardiovascular disease risk management in Australian general practice. Med J Aust 2009; 191: 324–329. https://www.mja.com.au/journal/2009/191/6/gaps-cardiovascular-disease-risk-management-australian-general-practice.
5. Joshi R, Patel A, Peiris D, et al. INTegrated Electronic General practice support tool, phaRmacy led intervention And combination Therapy Evaluation trial (INTEGRATE) [abstract]. Heart Lung Circ 2015; 24 (Suppl 3): S385.
6. Hespe CH. Q Pulse. Reducing cardiovascular disease (CVD): translating an evidence based quality improvement tool into “real‐world” general practice [ANZCTR registration: ACTRN 12615000108516]. Updated Jan 2018. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367376&isReview=true (viewed May 2020).
7. Heeley EL, Peiris DP, Patel AA, et al. Cardiovascular risk perception and evidence–practice gaps in Australian general practice (the AusHEART study). Med J Aust 2010; 192: 254–259. https://www.mja.com.au/journal/2010/192/5/cardiovascular-risk-perception-and-evidence-practice-gaps-australian-general.
8. Nieuwlaat RSJ, Khatib R, Yusuf S. Why are we failing to implement effective therapies in cardiovascular disease? Eur Heart J 2013; 34: 1262.
9. Sheppard JP, Fletcher K, McManus RJ, Mant J. Missed opportunities in prevention of cardiovascular disease in primary care: a cross‐sectional study. Br J Gen Prac 2014; 64: e38–e46.
10. Berwick DM. Lessons from developing nations on improving health care. BMJ 2004; 328: 1124–1129.

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Editorials

Frailty in older adults: moving from measurement to management

Emily H Gordon and Ruth E Hubbard

Med J Aust 2020; 213 (7): . || doi: 10.5694/mja2.50778
Published online: 5 October 2020

Topics

Gerontology

Health services administration

Incorporating routine assessment of frailty into health care would benefit both older people and the health system

The past two decades have seen a tremendous research effort dedicated to defining, measuring and validating the frailty construct. Large cohort studies of older adults living in the community have consistently found that frail people are at risk of a range of adverse outcomes, including death, disability, and institutionalisation.1 More recently, there has been a move from population‐based cohort studies of frailty to analyses of data collected during routine clinical encounters. In this issue of the MJA, Khadka and colleagues2 contribute to this body of translational research with a large retrospective cohort study of community‐dwelling Australians undergoing Aged Care Assessment Program (ACAP) eligibility assessment.

1 Centre for Health Services Research, University of Queensland, Brisbane, QLD
2 The University of Queensland, Brisbane, QLD

Correspondence: r.hubbard1@uq.edu.au

Competing interests:

No relevant disclosures.

1. Kojima G, Iliffe S, Walters K. Frailty index as a predictor of mortality: a systematic review and meta‐analysis. Age Ageing 2018; 47: 193–200.
2. Khadka J, Visvanathan R, Theou O, et al. Development and validation of a frailty index based on Australian Aged Care Assessment Program data. Med J Aust 2020; 213: 321–326.
3. Mitnitski A, Mogilner A, Rockwood K. Accumulation of deficits as a proxy measure of aging. ScientificWorldJournal 2001; 1: 323–336.
4. Rockwood K, Mitnitski A. Limits to deficit accumulation in elderly people. Mech Ageing Dev 2006; 127: 494–496.
5. Clegg A, Bates C, Young J, et al. Development and validation of an electronic frailty index using routine primary care electronic health record data. Age Ageing 2016; 45: 353–360.
6. Ludwig C, Busnel C. Derivation of a frailty index from the resident assessment instrument – home care adapted for Switzerland: a study based on retrospective data analysis. BMC Geriatr 2017; 17: 205.
7. Burn R, Hubbard R, Scrase R, et al. A frailty index derived from a standardized comprehensive geriatric assessment predicts mortality and aged residential care admission. BMC Geriatr 2018; 18: 319.
8. National Institute for Health and Care Excellence. Multimorbidity: clinical assessment and management (NICE guideline NG56). Sept 2016. https://www.nice.org.uk/guidance/ng56/resources/multimorbidity-clinical-assessment-and-management-pdf-1837516654789 (viewed Aug 2020).
9. NHS England. Supporting routine frailty identification and frailty through the GP Contract 2017/2018. Apr 2017; updated June 2019. https://www.england.nhs.uk/publication/supporting-routine-frailty-identification-and-frailty-through-the-gp-contract-20172018 (viewed Aug 2020).
10. Ellis G, Whitehead M, Robinson D, et al. Comprehensive geriatric assessment for older adults admitted to hospital: meta‐analysis of randomised controlled trials. BMJ 2011; 343: d6553.
11. Lin HS, Watts JN, Peel NM, Hubbard RE. Frailty and post‐operative outcomes in older surgical patients: a systematic review. BMC Geriatr 2016; 16: 157.
12. Poudel A, Peel N, Nissen L, et al. Adverse outcomes in relation to polypharmacy in robust and frail older hospital patients. J Am Med Dir Assoc 2016; 17: 767.e9–767.e13.

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Editorials

Red‐flagging the prescribing of oral corticosteroids for people with asthma

Christine F McDonald and Christopher J Worsnop

Med J Aust 2020; 213 (7): . || doi: 10.5694/mja2.50777
Published online: 5 October 2020

Topics

Endocrine system diseases

Respiratory tract diseases

Pharmaceutical preparations

High cumulative doses are often unnecessary and can have major adverse effects

The isolation of compound E, later known as cortisone, from the adrenal gland in 1949 led to its use for treating many medical conditions; the first randomised controlled trial of its benefit for people with asthma was published in 1956.1 However, adverse effects are associated with cumulative corticosteroid doses, both with long term continuous use of low dose preparations and with repeated short courses of high dose preparations. The introduction in 1970 of inhaled corticosteroids (ICS) revolutionised asthma management, providing anti‐inflammatory benefits with a markedly reduced side effect profile. Yet many people with asthma are less adherent to ICS use as preventive treatment than their health care professionals would wish. As many as 80% of patients do not adhere to preventive therapy as prescribed,2 and both practical and perceptual barriers to adherence have been described.3

Austin Hospital, Melbournne, VIC

Correspondence: Christine.McDonald@austin.org.au

Competing interests:

Christine McDonald has received speaker’s fees (paid to her organisation) from Menarini and Astra Zeneca. Christopher Worsnop has received speaker’s fees from HealthEd, GlaxoSmithKline, AstraZeneca, Cipla, Boehringer Ingelheim, Mundipharma, and Menarini.

1. Subcommittee on clinical trials in asthma. Controlled trial of effects of cortisone acetate in status asthmaticus: report to the Medical Research Council. Lancet 1956; 271: 803–806.
2. Bårnes CB, Ulrik CS. Asthma and adherence to inhaled corticosteroids: current status and future perspectives. Respir Care 2015; 60: 455–468.
3. Lindsay JT, Heaney LG. Nonadherence in difficult asthma: facts, myths, and a time to act. Patient Prefer Adherence 2013; 7: 329–336.
4. Hew M, McDonald VM, Bardin PG, et al. Cumulative dispensing of high oral corticosteroid doses for treating asthma in Australia. Med J Aust 2020; 213: 316–320.
5. Aaron SD, Vandemheen KL, FitzGerald JM, et al. Re‐evaluation of diagnosis in adults with physician‐diagnosed asthma. JAMA 2017; 317: 269–279.
6. Bateman ED, Boushey HA, Bousquet J, et al. Can guideline‐defined asthma control be achieved? Am J Respir Crit Care Med 2004; 170: 836–844.
7. Eger KAB, Amelink M, Hekking PP, Bel E. Overuse of oral corticosteroids in asthma‐modifiable factors and potential role of biologics. Eur Respir J 2019; 54 (Suppl 63): OA5334.

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Implementing cardiovascular disease preventive care guidelines in general practice: an opportunity missed

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