MJA
MJA

    Blood lead levels in children have fallen, but vigilance is still needed

    Mark P Taylor and Bruce P Lanphear
    Med J Aust 2020; 212 (4): . || doi: 10.5694/mja2.50495
    Published online: 2 March 2020

    Ongoing population‐level strategies are needed to further reduce lead exposure

    The largest survey of blood lead levels in children in Australia outside high risk mining and smelting communities since the phasing out of leaded petrol was undertaken as part of the Barwon Infant Study in Victoria. As reported in this issue of the MJA,1 the investigators found that blood lead concentrations in children were considerably lower (geometric mean, 0.95 μg/dL) than those measured in the last major survey of Australian children, more than 25 years ago (geometric mean, 5.05 μg/dL).2 Blood lead levels have declined dramatically over the past 50 years,3,4 and Symeonides and colleagues have found that levels in children continue to fall. Nevertheless, they are still about 60 times higher than in pre‐industrial humans (0.016 μg/dL),5 and health agencies have declared that there is no safe level of lead for children.6,7

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      Overdiagnosis of cancer in Australia: the role of screening

      David M Roder and Elizabeth Buckley
      Med J Aust 2020; 212 (4): . || doi: 10.5694/mja2.50494
      Published online: 2 March 2020

      The balance between benefits and risks could be improved if effective risk‐based screening protocols were developed

      Overdiagnosis can be defined as the proportion of diagnosed cancers that would not otherwise have come to a person's attention during their lifetime.1,2 Overdiagnosis provides no benefit to the patient but can have financial, psychosocial, and health consequences.2 While advances in imaging and other screening and diagnostic technologies can lead to therapeutic benefit, they can also increase overdiagnosis. Because overdiagnosed cancers are generally indistinguishable from potentially lethal cancers, the imperative to treat is equivalent.2


      • Cancer Research Institute, University of South Australia, Adelaide, SA


      Correspondence: david.roder@unisa.edu.au
      Competing interests:

      No relevant disclosures.

      • 1. Brodersen J, Schwartz LM, Heneghan C, et al. Overdiagnosis: what is it and what it isn't. BMJ Evid Based Med 2018; 23: 1–3.
      • 2. Marmot MG, Altman DG, Cameron DA, et al. The benefits and harms of breast cancer screening: an independent review. Br J Cancer 2013; 108: 2205–2240.
      • 3. Rainey L, van der Waal D, Jervaeus A, et al. Are we ready for the challenge of implementing risk‐based breast cancer screening and primary prevention? Breast 2018; 39: 24–32.
      • 4. Glasziou PP, Jones MA, Pathirana T, et al. Estimating the magnitude of cancer overdiagnosis in Australia. Med J Aust 2020; 212: 163–168.
      • 5. Esserman LJ, Thompson IM, Reid B, et al. Addressing overdiagnosis and overtreatment in cancer: a prescription for change. Lancet Oncol 2014; 15: e234–e242.
      • 6. Njor SH, Garne JP, Lynge E. Over‐diagnosis estimate from The Independent UK Panel on Breast Cancer Screening is based on unsuitable data. J Med Screen 2013; 20: 104–105.
      • 7. Morrell S, Gregory M, Sexton K, et al. Absence of sustained breast cancer incidence inflation in a national mammography screening programme. J Med Screen 2019; 26: 26–34.
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        How to perform a skin biopsy

        Kirsty JL Wark, Saxon D Smith and Deshan F Sebaratnam
        Med J Aust 2020; 212 (4): . || doi: 10.5694/mja2.50473
        Published online: 2 March 2020

        The skin has more disease processes than any other organ system in medicine, with over 3000 dermatological conditions described.1 Teaching of dermatology is often neglected in medical training internationally, and most doctors feel ill‐equipped to diagnose cutaneous pathology.2 Compounding this, limitations in access to specialist dermatologists in Australia are well recognised.3 Fortunately, biopsy of the skin is a simple skill to learn which can greatly help with the diagnosis of dermatological diseases. For cutaneous malignancies, the diagnosis is principally based on histopathological findings. However, for rashes, the correlation between clinical and pathological findings is paramount. For instance, observation of a lichenoid reaction pattern on skin biopsy may reflect lichen planus, lupus, dermatomyositis, lichen sclerosus, cutaneous T cell lymphoma, or graft‐versus‐host disease. To maximise the diagnostic yield of a skin biopsy, an understanding of the different types of biopsy, their indications and limitations is vital (Box 1 and Box 2).


        • 1 Liverpool Hospital, Sydney, NSW
        • 2 Royal North Shore Hospital, Sydney, NSW
        • 3 University of Sydney, Sydney, NSW
        • 4 Sydney Children's Hospitals Network, Sydney, NSW


        Correspondence: deshan@unsw.edu.au


        Series editors

        Balakrishnan (Kichu) Nair

        Simon O'Connor

        Acknowledgements: 

        We thank Alicia O'Connor, Anes Yang, Victoria Venning, Imogen Faulds and our patients for their contributions to the clinical images.

        Competing interests:

        No relevant disclosures.

        • 1. Bickers DR, Lim HW, Margolis D, et al. The burden of skin diseases: 2004: a joint project of the American Academy of Dermatology Association and the Society for Investigative Dermatology. J Am Acad Dermatol 2006; 55: 490–500.
        • 2. Hussain W, Hafiji J, Stanley AG, Khan KM. Dermatology and junior doctors: an evaluation of education, perceptions and self‐assessed competencies. Br J Dermatol 2008; 159: 505–506.
        • 3. Sebaratnam DF, Murrell DF. Dermatology training and practice in Australia. Int J Dermatol 2014; 53: 1259–1264.
        • 4. de Menezes SL, Kelly JW, Wolfe R, et al. The increasing use of shave biopsy for diagnosing invasive melanoma in Australia. Med J Aust 2019; 211: 213–218. https://www.mja.com.au/journal/2019/211/5/increasing-use-shave-biopsy-diagnosing-invasive-melanoma-australia
        • 5. Elston DM, Stratman EJ, Miller SJ. Skin biopsy: biopsy issues in specific diseases. J Am Acad Dermatol 2016; 74: 1–16.
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          Hidden in plain sight: umbilical melanoma

          Tom Kovitwanichkanont, Shoba Joseph and Leona Yip
          Med J Aust 2020; 212 (4): . || doi: 10.5694/mja2.50490
          Published online: 2 March 2020

          A 74‐year‐old Caucasian woman was referred for hirsutism over the abdomen and was incidentally found to have a 21 × 25 mm ulcerated nodule over the umbilicus (Box 1). This occurred on the background of a longstanding lesion. Over the previous 6 months, the nodule had become ulcerated and occasionally bled. The remainder of the full skin examination was unremarkable, with no concerning lesions or palpable regional lymphadenopathy. She had no previous malignancy but had a strong family history of colorectal, breast, lung and pharyngeal cancer. Results of investigations to exclude internal malignancies were normal. Following an initial incisional biopsy demonstrating malignant amelanotic melanoma, a subsequent wide local excision confirmed this to be a stage IIIC, extensively ulcerated invasive nodular melanoma of 21 mm thickness and Clark level IV, with a mitotic rate of up to 15/mm2. There was no lymphovascular or perineural invasion. Microsatellites, desmoplasia and regression were not identified. The melanoma was BRAF negative on both immunohistochemical and molecular testing. Sentinel lymph node biopsy showed two metastatic melanoma deposits in the left inguinal sentinel node. Initial staging evaluations showed no evidence of nodal or distant metastases on whole body positron emission tomography–computed tomography (PET–CT) and brain magnetic resonance imaging (MRI). The patient was commenced on adjuvant nivolumab immunotherapy, but 4 months into treatment was confirmed by biopsy to have recurrent left inguinal nodal metastatic disease, and a repeat PET–CT scan showed possible in‐transit metastasis in the abdominal wall. Dissection of the involved ilioinguinal lymph node and ultrasound‐guided removal of the abdominal metastatic deposit were being planned at the time of writing.


          • 1 Skin Health Institute, Melbourne, VIC
          • 2 Sinclair Dermatology, Melbourne, VIC
          • 3 Barton Specialist Centre, Canberra, ACT


          Acknowledgements: 

          We thank Miklos Pohl OAM and Dr Genevieve Bennett for their contributions to patient care.

          Competing interests:

          No relevant disclosures.

          • 1. Papalas JA, Selim MA. Metastatic vs primary malignant neoplasms affecting the umbilicus: clinicopathologic features of 77 tumors. Ann Diagn Pathol 2011; 15: 237–242.
          • 2. Campos‐Munoz L, Quesada‐Cortes A, Ruiz E, et al. Primary melanoma of the umbilicus appearing as omphalitis. Clin Exp Dermatol 2007; 32: 322–324.
          • 3. Colonna MR, Giovannini UM, Sturniolo G, Colonna U. The umbilicus: a rare site for melanoma. Clinical considerations in two cases. Case reports. Scand J Plast Reconstr Surg Hand Surg 1999; 33: 449–452.
          • 4. Steck WD, Helwig EB. Tumors of the umbilicus. Cancer 1965; 18: 907–915.
          • 5. Mar V, Roberts H, Wolfe R, et al. Nodular melanoma: a distinct clinical entity and the largest contributor to melanoma deaths in Victoria, Australia. J Am Acad Dermatol 2013; 68: 568–575.
          • 6. Gabriele R, Conte M, Egidi F, Borghese M. Umbilical metastases: current viewpoint. World J Surg Oncol 2005; 3: 13.
          • 7. Cancer Council Australia Melanoma Guidelines Working Party. Clinical practice guidelines for the diagnosis and management of melanoma. Sydney: Cancer Council Australia. 2019. https://wiki.cancer.org.au/australia/Guidelines:Melanoma (viewed Dec 2019).
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            Misgendering and experiences of stigma in health care settings for transgender people

            Irene J Dolan, Penelope Strauss, Sam Winter and Ashleigh Lin
            Med J Aust 2020; 212 (4): . || doi: 10.5694/mja2.50497
            Published online: 2 March 2020

            Misgendering negatively affects the mental and physical health of trans individuals

            Misgendering occurs when a person is addressed or described using language that does not match their gender identity.1 Misgendering within the health care system can significantly affect the mental and physical health of transgender (hereafter trans) individuals and can negatively impact future engagement with the health care system. Systemic policies and practices create situations which increase the likelihood of misgendering and experience of stigma, affecting the delivery of health care to trans individuals.


            • 1 HealthPathways WA, Perth, WA
            • 2 Telethon Kids Institute, Perth, WA
            • 3 University of Western Australia, Perth, WA
            • 4 Curtin University, Perth, WA


            Correspondence: irene.dolan@wapha.org.au
            Acknowledgements: 

            Ashleigh Lin is supported by a National Health and Medical Research Council Career Development Fellowship (1148793).

            Competing interests:

            No relevant disclosures.

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              Bushfire smoke: urgent need for a national health protection strategy

              Sotiris Vardoulakis, Bin B Jalaludin, Geoffrey G Morgan, Ivan C Hanigan and Fay H Johnston
              Med J Aust 2020; 212 (8): . || doi: 10.5694/mja2.50511
              Published online: 24 February 2020

              More nuanced health advice is needed to protect populations and individuals from exposure to bushfire smoke

              Bushfires have always been a feature of the natural environment in Australia, but the risk has increased over time as fire seasons start earlier, finish later, and extreme fire weather (ie, very hot, dry and windy conditions that make fires fast moving and very difficult to control) becomes more severe with climate change.1,2,3 The 2019–20 bushfires in Australia, particularly in New South Wales, Victoria, Queensland and the Australian Capital Territory, have caused at least 33 fatalities, extensive damage to property and destruction of flora and fauna, and have exposed millions of people to extreme levels of air pollution. Bushfire smoke, as well as smoke from prescribed burns, contains a complex mixture of particles and gases that are chemically transformed in the atmosphere and transported by the wind over long distances.4 In this context, a major public health concern is population exposure to atmospheric particulate matter (PM) with a diameter < 2.5 μm (PM2.5), which can penetrate deep into the respiratory system, inducing oxidative stress and inflammation,5 and even translocate into the bloodstream.6

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              • 1 National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, ACT
              • 2 Ingham Institute for Applied Medical Research, University of New South Wales
              • 3 School of Public Health and University Centre for Rural Health, University of Sydney, Sydney, NSW
              • 4 Health Research Institute, University of Canberra, ACT
              • 5 Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS


              Acknowledgements: 

              This research was undertaken with support from the Australian National University College of Health and Medicine, and the assistance of resources from the Centre for Air pollution, energy and health Research (CAR). We used the CAR Data and Analysis Technology platform (https://cardat.github.io) to analyse data.

              Competing interests:

              Sotiris Vardoulakis has received funding support from the UK National Institute for Health Research, Medical Research Council, Natural Environment Research Council, Public Health England, EU Horizon 2020, and Dyson Ltd. Geoffrey Morgan and Ivan Hanigan receive funding support from the Australian National Health and Medical Research Council.

              • 1. Harris S, Lucas C. Understanding the variability of Australian fire weather between 1973 and 2017. PLoS One 2019; 14: e0222328.
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              • 3. Beggs PJ, Zhang Y, Bambrick H, et al. The 2019 report of the MJA–Lancet Countdown on health and climate change: a turbulent year with mixed progress. Med J Aust 2019; 211: 490–491.e21. https://www.mja.com.au/journal/2019/211/11/2019-report-mja-lancet-countdown-health-and-climate-change-turbulent-year-mixed
              • 4. Johnston FH. Understanding and managing the health impacts of poor air quality from landscape fires. Med J Aust 2017; 207: 229–230. https://www.mja.com.au/journal/2017/207/6/understanding-and-managing-health-impacts-poor-air-quality-landscape-fires.
              • 5. Lodovici M, Bigagli E. Oxidative stress and air pollution exposure. J Toxicol 2011; 2011: 487074.
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              • 7. Morgan G, Sheppeard V, Khalaj B, et al. Effects of bushfire smoke on daily mortality and hospital admissions in Sydney. Australia. Epidemiology 2010; 21: 47–55.
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              • 14. Melody SM, Ford JB, Wills K, et al. Maternal exposure to fine particulate matter from a large coal mine fire is associated with gestational diabetes mellitus: a prospective cohort study. Environ Res 2019; 108956 [Epub ahead of print].
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              • 19. Lin Z, Chen R, Jiang Y, et al. Cardiovascular benefits of fish‐oil supplementation against fine particulate air pollution in China. J Am Coll Cardiol 2019; 73: 2076–2085.
              • 20. Cherrie JW, Apsley A, Cowie H, et al. Effectiveness of face masks used to protect Beijing residents against particulate air pollution. Occup Environ Med 2018; 75: 446–452.
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              Online responses are no longer available. Please refer to our instructions for authors page for more information.

                Advances in type 2 diabetes therapy: a focus on cardiovascular and renal outcomes

                Renata Libianto, Timothy ME Davis and Elif I Ekinci
                Med J Aust 2020; 212 (3): . || doi: 10.5694/mja2.50472
                Published online: 17 February 2020

                Summary

                • Treatment options for type 2 diabetes have expanded. While metformin remains the first line treatment in most cases, choices for second line treatment now extend beyond sulfonylureas and include the sodium–glucose cotransporter 2 (SGLT2) inhibitors, glucagon‐like peptide 1 (GLP1) receptor agonists, and dipeptidyl peptidase 4 (DPP4) inhibitors.
                • SGLT2 inhibitors are recommended for people with atherosclerotic cardiovascular disease, heart failure or kidney disease. Diabetic ketoacidosis is an uncommon but important side effect; its occurrence can be minimised with appropriate patient education and management, especially during perioperative periods and times of illness.
                • GLP1 receptor agonists are recommended for people with atherosclerotic cardiovascular disease. Gastrointestinal side effects are common but are less prominent with the longer acting agents and can be minimised with slow titration of the shorter acting agents.
                • DPP4 inhibitors are generally well tolerated, but alogliptin and saxagliptin should be used with caution in people with risk factors for heart failure.
                • To optimise the management of type 2 diabetes, clinicians need to be aware of the pharmacological characteristics of each class of blood glucose‐lowering medications and of the effect on cardiovascular health and renal function, balanced by potential adverse effects.
                • Medications that have cardiovascular or renal benefits should be prescribed for patients with these comorbidities, and this is reflected in recent international guidelines.

                • 1 Melbourne University, Melbourne, VIC
                • 2 University of Western Australia, Perth, WA
                • 3 Austin Health, Melbourne, VIC


                Correspondence: elif.ekinci@unimelb.edu.au
                Acknowledgements: 

                Renata Libianto is supported by a National Health and Medical Research Council/National Heart Foundation of Australia postgraduate scholarship and by the Royal Australasian College of Physicians (RACP). Timothy Davis is supported by a Medical Research Future Fund Next Generation Clinical Researchers Program Practitioner Fellowship. Elif Ekinci has received grant funding from Viertel, RACP, Sir Edward Weary Dunlop Medical Research Foundation, and Diabetes Australia Research Program.

                Competing interests:

                Elif Ekinci's institute has received research funding from Novo Nordisk, Sanofi, GeNeuro and Dimerix. Timothy Davis has served on advisory boards for, and received research funding, speaker fees and travel assistance to attend meetings from, Merck Sharp and Dohme (manufacturer of sitagliptin and ertugliflozin), NovoNordisk (manufacturer of liraglutide and semaglutide), and Eli Lilly (manufacturer of dulaglutide). He has also served on advisory boards for, and received speaker fees and travel assistance to attend meetings from, AstraZeneca (manufacturer of saxagliptin, exenatide and dapagliflozin) and Boehringer Ingelheim (manufacturer of linagliptin and empagliflozin).

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                  Incidence and prevalence of self‐reported non‐coeliac wheat sensitivity and gluten avoidance in Australia

                  Michael DE Potter, Michael P Jones, Marjorie M Walker, Natasha A Koloski, Simon Keely, Gerald Holtmann and Nicholas J Talley AC
                  Med J Aust 2020; 212 (3): . || doi: 10.5694/mja2.50458
                  Published online: 17 February 2020

                  Abstract

                  Objectives: To determine the incidence of self‐reported non‐coeliac wheat sensitivity (SR‐NCWS) and factors associated with its onset and resolution; to describe the prevalence of factors associated with gluten avoidance.

                  Design: Longitudinal cohort study; analysis of responses to self‐administered validated questionnaires (Digestive Health and Wellbeing surveys, 2015 and 2018).

                  Setting, participants: Subset of an adult population sample randomly selected in 2015 from the electoral rolls for the Newcastle and Gosford regions of New South Wales.

                  Main outcome measures: Prevalence of SR‐NCWS (2015, 2018) and incidence and resolution of SR‐NCWS, each by demographic and medical factors; prevalence of gluten avoidance and reasons for gluten avoidance (2018).

                  Results: 1322 of 2185 eligible participants completed the 2018 survey (response rate, 60.5%). The prevalence of SR‐NCWS was similar in 2015 (13.8%; 95% CI, 12.0–15.8%) and 2018 (13.9%; 95% CI, 12.1–15.9%); 69 of 1301 respondents (5.3%) reported developing new onset (incident) SR‐NCWS between 2015 and 2018 (incidence, 1.8% per year). Incident SR‐NCWS was significantly associated with a diagnosis of functional dyspepsia, and negatively associated with being male or older. Gluten avoidance was reported in 2018 by 24.2% of respondents (20.5% partial, 3.8% complete avoidance); general health was the most frequent reason for avoidance (168 of 316 avoiders, 53%). All 13 participants with coeliac disease, 56 of 138 with irritable bowel syndrome (41%), and 69 of 237 with functional dyspepsia (29%) avoided dietary gluten.

                  Conclusions: The prevalence of SR‐NCWS was similar in 2015 and 2018. Baseline (2015) and incident SR‐NCWS (2018) were each associated with functional gastrointestinal disorders. The number of people avoiding dietary gluten exceeds that of people with coeliac disease or SR‐NCWS, and general health considerations and abdominal symptoms are the most frequently reported reasons for avoidance.

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                  • 1 University of Newcastle, Newcastle, NSW
                  • 2 John Hunter Hospital, Newcastle, NSW
                  • 3 Macquarie University, Sydney, NSW
                  • 4 University of Queensland, Brisbane, QLD
                  • 5 Princess Alexandra Hospital, Brisbane, QLD


                  Acknowledgements: 

                  This project was partially supported by a grant from Prometheus Laboratories.

                  Competing interests:

                  No relevant disclosures.

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                    The incidence of childhood cancer in Australia, 1983–2015, and projections to 2035

                    Danny R Youlden, Peter D Baade, Adèle C Green, Patricia C Valery, Andrew S Moore and Joanne F Aitken
                    Med J Aust 2020; 212 (3): . || doi: 10.5694/mja2.50456
                    Published online: 17 February 2020

                    Abstract

                    Objectives: To describe changes in childhood cancer incidence in Australia, 1983–2015, and to estimate projected incidence to 2035.

                    Design, setting: Population‐based study; analysis of Australian Childhood Cancer Registry data for the 20 547 children under 15 years of age diagnosed with cancer in Australia between 1983 and 2015.

                    Main outcome measures: Incidence rate changes during 1983–2015 were assessed by joinpoint regression, with rates age‐standardised to the 2001 Australian standard population. Incidence projections to 2035 were estimated by age‐period‐cohort modelling.

                    Results: The overall age‐standardised incidence rate of childhood cancer increased by 34% between 1983 and 2015, increasing by 1.2% (95% CI, +0.5% to +1.9%) per annum between 2005 and 2015. During 2011–2015, the mean annual number of children diagnosed with cancer in Australia was 770, an incidence rate of 174 cases (95% CI, 169–180 cases) per million children per year. The incidence of hepatoblastoma (annual percentage change [APC], +2.3%; 95% CI, +0.8% to +3.8%), Burkitt lymphoma (APC, +1.6%; 95% CI, +0.4% to +2.8%), osteosarcoma (APC, +1.1%; 95%, +0.0% to +2.3%), intracranial and intraspinal embryonal tumours (APC, +0.9%; 95% CI, +0.4% to +1.5%), and lymphoid leukaemia (APC, +0.5%; 95% CI, +0.2% to +0.8%) increased significantly across the period 1983–2015. The incidence rate of childhood melanoma fell sharply between 1996 and 2015 (APC, –7.7%; 95% CI, –10% to –4.8%). The overall annual cancer incidence rate is conservatively projected to rise to about 186 cases (95% CI, 175–197 cases) per million children by 2035 (1060 cases per year).

                    Conclusions: The incidence rates of several childhood cancer types steadily increased during 1983–2015. Although the reasons for these rises are largely unknown, our findings provide a foundation for health service planning for meeting the needs of children who will be diagnosed with cancer until 2035.

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                    • 1 Cancer Council Queensland, Brisbane, QLD
                    • 2 Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD
                    • 3 Queensland University of Technology, Brisbane, QLD
                    • 4 QIMR Berghofer Medical Research Institute, Brisbane, QLD
                    • 5 Cancer Research UK Manchester Institute, Manchester University, Manchester, United Kingdom
                    • 6 Children's Health, Queensland Hospital and Health Service, Brisbane, QLD
                    • 7 Child Health Research Centre, University of Queensland, Brisbane, QLD
                    • 8 Institute for Resilient Regions, University of Southern Queensland, Brisbane, QLD
                    • 9 University of Queensland, Brisbane, QLD


                    Acknowledgements: 

                    Patricia Valery was supported by an NHMRC Career Development Fellowship (1083090). We thank Leisa O'Neill for her work in the Australian Childhood Cancer Registry. We also acknowledge the assistance of all Australian state and territory cancer registries, the Australian Institute of Health and Welfare, and each of the major paediatric oncology treating hospitals throughout Australia.

                    Competing interests:

                    No relevant disclosures.

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                      Implementing value‐based health care at scale: the NSW experience

                      Elizabeth Koff and Nigel Lyons
                      Med J Aust 2020; 212 (3): . || doi: 10.5694/mja2.50470
                      Published online: 17 February 2020

                      What is value in health care and how can the system deliver it at scale?

                      The New South Wales health system exemplifies the worldwide challenge of health service sustainability. With 234 public hospitals and facilities employing over 130 000 staff, the system provides universal access to health care for a growing population of almost 8 million people across a diverse geography of over 800 000 km2. The NSW Health budget in 2018–19 was $25 billion,1 representing over 25% of the annual state budget. As with all health systems, NSW Health is experiencing growing pressure from chronic disease, an ageing population and the use of new technology. In response, optimising health system access and efficiency has been central to health reform in NSW.2


                      • NSW Health, Sydney, NSW


                      Competing interests:

                      No relevant disclosures.

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