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    The Australian Aboriginal Birth Cohort study: socio‐economic status at birth and cardiovascular risk factors to 25 years of age

    Markus Juonala, Pauline Sjöholm, Katja Pahkala, Susan Ellul, Noora Kartiosuo, Belinda Davison and Gurmeet R Singh
    Med J Aust 2019; 211 (6): . || doi: 10.5694/mja2.50285
    Published online: 26 August 2019

    Abstract

    Objectives: To determine whether socio‐economic status at birth is associated with differences in risk factors for cardiovascular disease — body mass index (BMI), blood pressure, blood lipid levels — during the first 25 years of life.

    Design: Analysis of prospectively collected data.

    Setting, participants: 570 of 686 children born to Aboriginal mothers at the Royal Darwin Hospital during 1987–1990 and recruited for the Aboriginal Birth Cohort Study in the Northern Territory. Participants resided in 46 urban and remote communities across the NT. The analysed data were collected at three follow‐ups: Wave 2 in 1998–2001 (570 participants; mean age, 11 years), Wave 3 in 2006–2008 (442 participants; mean age, 18 years), and Wave 4 in 2014–2016 (423 participants; mean age, 25 years).

    Main outcome measures: Cardiovascular disease risk factors by study wave and three socio‐economic measures at the time of birth: area‐level Indigenous Relative Socioeconomic Outcomes (IRSEO) index score and location (urban, remote) of residence, and parity of mother.

    Results: Area‐level IRSEO of residence at birth influenced BMI (P < 0.001), systolic blood pressure (P = 0.024), LDL‐cholesterol (P = 0.010), and HDL‐cholesterol levels (P < 0.001). Remoteness of residence at birth influenced BMI (P < 0.001), HDL‐cholesterol (P < 0.001), and triglyceride levels (P = 0.043). Mother's parity at birth influenced BMI (P = 0.039).

    Conclusions: Our longitudinal life course analyses indicate that area‐level socio‐economic factors at birth influence the prevalence of major cardiovascular disease risk factors among Indigenous Australians during childhood and early adulthood.

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    • 1 Turun Yliopisto (University of Turku), Turku, Finland
    • 2 Turku University Hospital, Turku, Finland
    • 3 Murdoch Children's Research Institute, Melbourne, VIC
    • 4 Research Centre of Applied and Preventive Cardiovascular Medicine, Turun Yliopisto, Turku, Finland
    • 5 Menzies School of Health Research, Darwin, NT


    Correspondence: mataju@utu.fi
    Acknowledgements: 

    We acknowledge past and present study team members, particularly the late Susan Sayers AO, founder of the Aboriginal Birth Cohort study. We especially thank the young adults in the Aboriginal Birth Cohort and their families and communities for their cooperation and support, and all the individuals who helped in urban and rural locations. The investigation was supported by the National Health and Medical Research Council, the Channel 7 Children's Research Foundation of South Australia, the National Heart Foundation, a Northern Territory Government Research and Innovation Grant, the Juho Vainio Foundation, the Turku University Hospital, and the Finnish Foundation for Cardiovascular Research. The sponsors had no role in preparing the manuscript.

    Competing interests:

    No relevant disclosures.

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      Adherence to screen time recommendations for Australian children aged 0–12 years

      Leigh Tooth, Katrina Moss, Richard Hockey and Gita D Mishra
      Med J Aust 2019; 211 (4): . || doi: 10.5694/mja2.50286
      Published online: 19 August 2019

      Australian Department of Health guidelines recommend that children under 2 years of age have no screen time, a limit of one hour per day for 2–5‐year‐old children, and a limit of 2 hours of recreational screen time per day for 5–17‐year‐old children.1 As it has not been assessed in a nationally representative study, we examined adherence to these recommendations among children aged 0–12 years, as well as the characteristics of children, their mothers, and their homes associated with non‐adherence.

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      • University of Queensland, Brisbane, QLD


      Correspondence: l.tooth@sph.uq.edu.au
      Acknowledgements: 

      This investigation was part of the Australian Longitudinal Study on Women's Health by the University of Queensland and the University of Newcastle. We thank the Australian Department of Health for funding and the women who provided the survey data. The MatCH study is funded by the National Health and Medical Research Council (NHMRC) (1059550); Gita Mishra has an NHMRC Principal Research Fellowship (1121844).

      Competing interests:

      No relevant disclosures.

      • 1. Australian Department of Health. Australia's Physical Activity and Sedentary Behaviour Guidelines and the Australian 24‐Hour Movement Guidelines. Updated Apr 2019. http://www.health.gov.au/internet/main/publishing.nsf/content/health-pubhlth-strateg-phys-act-guidelines#npa05 (viewed June 2019).
      • 2. Dobson A, Hockey R, Brown W, et al. Cohort profile update: Australian Longitudinal Study on Women's Health. Int J Epidemiol 2015; 44: 1547, 1547a–1547f.
      • 3. Mishra GD, Moss K, Loos C, et al. MatCH (Mothers and their Children's Health) profile: offspring of the 1973–78 cohort of the Australian Longitudinal Study on Women's Health. Longitudinal and Life Course Studies 2018; 9: 351–375; https://doi.org/10.14301/llcs.v9i3.491 (viewed June 2019).
      • 4. Madigan S, Browne D, Racine N. Association between screen time and children's performance on a developmental screening test. JAMA Pediatr 2019; 173: 244–250.
      • 5. Stiglic N, Viner RM. Effects of screen time on the health and well‐being of children and adolescents: a systematic review of reviews. BMJ Open 2019; 9: e023191.

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        Antibiotic use in animals and humans in Australia

        Freya Langham and Allen C Cheng
        Med J Aust 2019; 211 (4): . || doi: 10.5694/mja2.50258
        Published online: 19 August 2019

        Developing strategies to reduce both the transmission of important pathogens and antimicrobial resistance is of paramount importance

        Since the 1960s, there has been concern about the use of antibiotics in food animals and its contribution to antibiotic resistance in humans. The increasing intensification of modern food animal production has resulted in an increase in antimicrobial use in livestock, for both therapeutic and non‐therapeutic purposes. There are a number of mechanisms by which antimicrobial use in animals affects resistance in human pathogens, such as transmission by direct contact and, indirectly, through food consumption and environmental contamination.1 Moreover, there is emerging literature stating that limiting antimicrobial use in animals leads to reduced resistance in humans.2


        • 1 Alfred Health, Melbourne, VIC
        • 2 Monash University, Melbourne, VIC


        Correspondence: f.langham@alfred.org.au
        Competing interests:

        No relevant disclosures.

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          Controversies in medicine: redefining the diagnosis of type 1 diabetes

          Jennifer J Couper and Leonard C Harrison
          Med J Aust 2019; 211 (4): . || doi: 10.5694/mja2.50284
          Published online: 19 August 2019

          Diagnosis of autoimmune β-cell disorder before end-stage clinical type 1 diabetes is a key step towards the prevention of this disease


          • 1 Women's and Children's Hospital, Adelaide, SA
          • 2 University of Adelaide, Adelaide, SA
          • 3 Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC


          Acknowledgements: 

          We acknowledge the contributions to the manuscript of Megan Penno and the community support and perspective provided by Juvenile Diabetes Research Foundation Australia, the recipient of the Australian Research Council Special Research Initiative in Type 1 Diabetes. Leonard Harrison was supported by a National Health and Medical Research Council Senior Principal Research Fellowship (1080887).

          Competing interests:

          No relevant disclosures.

          • 1. Haynes A, Bulsara MK, Bower C, et al. Regular peaks and troughs in the Australian incidence of childhood type 1 diabetes mellitus (2000–2011). Diabetologia 2015; 58: 2513–2516.
          • 2. Phelan H, Clapin H, Bruns L, et al. The Australasian Diabetes Data Network: first national audit of children and adolescents with type 1 diabetes. Med J Aust 2017; 206: 121–125. https://www.mja.com.au/journal/2017/206/3/australasian-diabetes-data-network-first-national-audit-children-and-adolescents
          • 3. Ziegler AG, Rewers M, Simell O, et al. Seroconversion to multiple islet autoantibodies and risk of progression to diabetes in children. JAMA 2013; 309: 2473–2479.
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          • 8. Department of Health. Australian National Diabetes Strategy 2016–2020. Canberra: Commonwealth of Australia, 2015. http://www.health.gov.au/internet/main/publishing.nsf/Content/nds-2016-2020 (viewed Jan 2019).
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          • 16. Bingley PJ, Bonifacio E, Williams AJ, et al. Prediction of IDDM in the general population: strategies based on combinations of autoantibody markers. Diabetes 1997; 46: 1701–1710.

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            Primary prevention implantable cardioverter defibrillators in non‐ischaemic cardiomyopathy: challenging the Australian heart failure guidelines

            Dennis H Lau, Jonathan M Kalman and Prashanthan Sanders
            Med J Aust 2019; 211 (4): . || doi: 10.5694/mja2.50248
            Published online: 19 August 2019

            The 2018 Australian guidelines recommendations require further clarification to ensure eligible patients will receive appropriate ICD therapy

            The implantable cardioverter defibrillator (ICD) has been shown to be a cost‐effective option for primary prevention of sudden cardiac death (SCD) in patients with heart failure with reduced ejection fraction (HFrEF). However, in the recently published 2018 guidelines for the prevention, detection and management of heart failure in Australia, the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand Heart Failure Guidelines Working Group downgraded the recommendation for primary prevention ICD to decrease mortality in patients with HFrEF and left ventricular ejection fraction (LVEF) 35% or below associated with non‐ischaemic cardiomyopathy (NICM).1,2 In particular, the level of recommendation and quality of evidence for primary prevention ICD was deemed weak and low for NICM versus strong and moderate for ischaemic cardiomyopathy, respectively. The document cited the lack of single randomised controlled trials demonstrating mortality benefits with primary prevention ICD in patients with NICM. It also highlighted recent prospective randomised controlled data of 1116 patients with HFrEF and LVEF 35% or below associated with non‐ischaemic causes from the DANISH trial — a Danish study to assess the efficacy of ICD in patients with non‐ischaemic systolic heart failure on mortality — whereby primary prevention ICD did not reduce mortality compared with usual clinical care over a median follow‐up duration of 67.6 months (interquartile range, 49–85 months).3


            • 1 Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, SA
            • 2 Royal Adelaide Hospital, Adelaide, SA
            • 3 University of Melbourne, Melbourne, VIC
            • 4 Royal Melbourne Hospital, Melbourne, VIC


            Acknowledgements: 

            Dennis Lau is supported by the Robert J Craig Lectureship from the University of Adelaide. Jonathan Kalman and Prashanthan Sanders are supported by Practitioner Fellowships from the National Health and Medical Research Council. Prashanthan Sanders is supported by the National Heart Foundation of Australia.

            Competing interests:

            The University of Adelaide reports receiving on behalf of Dennis Lau lecture and/or consulting fees from Abbott, Bayer, Biotronik and Pfizer. Prashanthan Sanders reports having served on the advisory board of Biosense‐Webster, Medtronic, Abbott, Boston Scientific and CathRx. The University of Adelaide reports receiving on behalf of Prashanthan Sanders lecture and/or consulting fees from Biosense‐Webster, Medtronic, Abbott, and Boston Scientific. The University of Adelaide reports receiving on behalf of Prashanthan Sanders research funding from Medtronic, Abbott, Boston Scientific, Biotronik and Liva Nova.

            • 1. Atherton JJ, Sindone A, De Pasquale CG, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of heart failure 2018. Med J Aust 2018; 209: 363–369. https://www.mja.com.au/journal/2018/209/8/national-heart-foundation-australia-and-cardiac-society-australia-and-new-0
            • 2. Atherton JJ, Sindone A, De Pasquale CG, et al; NHFA CSANZ Heart Failure Guidelines Working Group. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: guidelines for the prevention, detection, and management of heart failure in Australia 2018. Heart Lung Circ 2018; 27: 1123–1208.
            • 3. Kober L, Thune JJ, Nielsen JC, et al. Defibrillator implantation in patients with nonischemic systolic heart failure. N Engl J Med 2016; 375: 1221–1230.
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            • 11. Bristow MR, Saxon LA, Boehmer J, et al; Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) Investigators. Cardiac‐resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 2004; 350: 2140–2150.
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            • 13. Elming MB, Nielsen JC, Haarbo J, et al. Age and outcomes of primary prevention implantable cardioverter‐defibrillators in patients with nonischemic systolic heart failure. Circulation 2017; 136: 1772–1780.
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            • 16. Pathak RK, Sanders P, Deo R. Primary prevention implantable cardioverter‐defibrillator and opportunities for sudden cardiac death risk assessment in non‐ischaemic cardiomyopathy. Eur Heart J 2018; 39: 2859–2866.

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              The future of academic publishing: disruption, opportunity and a new ecosystem

              Virginia Barbour
              Med J Aust 2019; 211 (4): . || doi: 10.5694/mja2.50265
              Published online: 19 August 2019

              Academic publishing is on an irreversible path to change

              It is not a hyperbole to say that the foundations of academic publishing are in a state of large‐scale disruption. That this disruption remains largely under the surface is primarily because the main users of academic research — those who work at universities — rarely suffer the consequences of lack of access due to the substantial payments universities make for subscription journals (about $281 million in total in Australia in 2017).1 Outside of universities, however, gaining online access to published research legally is neither easy nor affordable. Furthermore, as we move towards an interconnected digital future, it is becoming increasingly obvious that a system whose core business model rests on controlling access is an anachronism.

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              • Queensland University of Technology, Brisbane, QLD


              Correspondence: Ginny.Barbour@qut.edu.au
              Competing interests:

              Virginia Barbour is member of the NHMRC Research Quality Steering Committee and is employed by the Australasian Open Access Strategy Group. She was previously employed by PLOS, was Chair of the Committee on Publication Ethics, and is currently Chair of the DORA international advisory committee and a Plan S ambassador.

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                Advancing women in medical leadership

                Helena J Teede
                Med J Aust 2019; 211 (9): . || doi: 10.5694/mja2.50287
                Published online: 12 August 2019

                Equity underpins workforce diversity, embraces and values differences, harnesses talents and skills, and represents and responds to community needs


                • Monash Partners Academic Health Sciences Centre, Monash University and Monash Health, Melbourne, VIC


                Correspondence: helena.teede@monash.edu
                Acknowledgements: 

                I have held National Health Medical and Research Council fellowship funding throughout my clinical academic career and have been employed and supported through leadership training and career development opportunities by both Monash University and Monash Health. I acknowledge the many women and men who have provided mentorship throughout my career. I thank Heidi Burgmeier for critical input into the manuscript and Anjali Dhulia for her role in the Monash Health Women in Leadership initiatives.

                Competing interests:

                Helena Teede runs and facilitates Women in Leadership training programs with Monash Health and Monash University with all funds going to the institution.

                • 1. International Labour Office. ABC of women workers’ rights and gender equality. 2nd ed. Geneva: International Labour Organization, 2007. https://www.ilo.org/wcmsp5/groups/public/-dgreports/-gender/documents/publication/wcms_087314.pdf (viewed Oct 2018).
                • 2. American College of Healthcare Executives. A comparison of the career attainments of men and women healthcare executives [website]. https://www.ache.org/learning-center/research/about-the-workplace/gender-studies/a-comparison-of-the-career-attainments-of-men-and-women-healthcare-executives; (viewed Oct 2018).
                • 3. Bismark M, Morris J, Thomas L, et al. Reasons and remedies for under‐representation of women in medical leadership roles: a qualitative study from Australia. BMJ Open 2015; 5: e009384.
                • 4. Ibarra H, Ely R, Kolb D. Women rising: the unseen barriers. Harvard Business Review 2013; Sept. https://hbr.org/2013/09/women-rising-the-unseen-barriers (viewed Oct 2018).
                • 5. Clark J, Zuccala E, Horton R. Women in science, medicine, and global health: call for papers. Lancet 2017; 390: 2423–2424.
                • 6. Weiss A, Lee KC, Tapia V, et al. Equity in surgical leadership for women: more work to do. Am J Surg 2014; 208: 494–498.
                • 7. Carnes M, Bairey Merz CN. Women are less likely than men to be full professors in cardiology. Circulation 2017; 135: 518–520.
                • 8. Santen RJ, Joham A, Fishbein L, et al. Career advancement: meeting the challenges confronting the next generation of endocrinologists and endocrine researchers. J Clin Endocrinol Metab 2016; 101: 4512–4520.
                • 9. Australian Institute of Health and Welfare. Medical workforce 2011. [National Health Workforce Series; Cat. No. HWL49] Canberra: AIHW, 2011. https://www.aihw.gov.au/reports/workforce/medical-workforce-2011/contents/table-of-contents (viewed June 2019).
                • 10. Hauser MC. Leveraging women's leadership talent in healthcare. J Healthc Manag 2014; 59: 318–322.
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                  Infections in pregnancy

                  Caitlin L Keighley, Hannah JM Skrzypek, Angela Wilson, Michael A Bonning and Gwendolyn L Gilbert
                  Med J Aust 2019; 211 (3): . || doi: 10.5694/mja2.50261
                  Published online: 5 August 2019

                  Summary

                  • Infections in pregnancy represent a challenging and often underappreciated area of concern for many specialists and general practitioners and can cause serious sequelae.
                  • Antenatal status should be highlighted on pathology request forms, as this serves to alert the laboratory of the need to store serum for an extended period. Prior antenatal specimens can be forwarded to other laboratories to enable testing in parallel with the more recent sample.
                  • Women with a confirmed, potentially vertically transmissible infection should be referred to a specialist with expertise in the management of perinatal infections.
                  • Cytomegalovirus infection is the most common congenital infection. Women who care for young children are at greater risk of exposure to the virus. Preventive steps including hand hygiene and avoiding contact with children's urine, mucous and saliva are recommended for all pregnant women.
                  • The incidence of parvovirus B19 infection in pregnancy is unknown. This infection is highly contagious and may result in fetal loss; particularly in the first half of pregnancy, pregnant women should avoid contact with adults or children who may have an infection.

                  • 1 Institute for Clinical Pathology and Medical Research, NSW Health Pathology Centre for Infectious Diseases and Microbiology, Sydney, NSW
                  • 2 University of Sydney, Sydney, NSW
                  • 3 Mercy Hospital for Women, Melbourne, VIC
                  • 4 Alice Springs Hospital, Alice Springs, NT
                  • 5 GP Synergy, Sydney, NSW
                  • 6 Macquarie University, Sydney, NSW
                  • 7 Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW
                  • 8 Sydney Health Ethics, University of Sydney, Sydney, NSW


                  Competing interests:

                  No relevant disclosures.

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                    Position statement on the hormonal management of adult transgender and gender diverse individuals

                    Ada S Cheung, Katie Wynne, Jaco Erasmus, Sally Murray and Jeffrey D Zajac
                    Med J Aust 2019; 211 (3): . || doi: 10.5694/mja2.50259
                    Published online: 5 August 2019

                    Abstract

                    Introduction: Rising demand for gender‐affirming hormone therapy mandates a need for more formalised care of transgender and gender diverse (TGD) individuals in Australia. Estimates suggest that 0.1–2.0% of the population are TGD, yet medical education in transgender health is lacking. We aim to provide general practitioners, physicians and other medical professionals with specific Australian recommendations for the hormonal and related management of adult TGD individuals.

                    Main recommendations:

                    • Hormonal therapy is effective at aligning physical characteristics with gender identity and in addition to respectful care, may improve mental health symptoms.
                    • Masculinising hormone therapy options include transdermal or intramuscular testosterone at standard doses.
                    • Feminising hormone therapy options include transdermal or oral estradiol. Additional anti‐androgen therapy with cyproterone acetate or spironolactone is typically required.
                    • Treatment should be adjusted to clinical response. For biochemical monitoring, target estradiol and testosterone levels in the reference range of the affirmed gender.
                    • Monitoring is suggested for adverse effects of hormone therapy.
                    • Preferred names in use and pronouns should be used during consultations and reflected in medical records.
                    • While being TGD is not a mental health disorder, individualised mental health support to monitor mood during medical transition is recommended.

                     

                    Changes in management as result of this position statement: Gender‐affirming hormone therapy is effective and, in the short term, relatively safe with appropriate monitoring. Further research is needed to guide clinical care and understand long term effects of hormonal therapies. We provide the first guidelines for medical practitioners to aid the provision of gender‐affirming care for Australian adult TGD individuals.

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                    • 1 Austin Health, University of Melbourne, Melbourne, VIC
                    • 2 Diabetes and Endocrinology, Hunter New England Health, Newcastle, NSW
                    • 3 Gender Clinic, Monash Health, Melbourne, VIC
                    • 4 Sexual Health Service, Royal Perth Hospital, Perth, WA


                    Correspondence: adac@unimelb.edu.au
                    Acknowledgements: 

                    The figure in Box 2 was designed for this article by graphic artist Jake Kidson‐Purry. We thank TGD community members who reviewed and provided feedback on the position statement: Daria Chetcuti, Max Rainier, Alex Wong andTransgender Victoria committee members. We also thank expert reviewers Ruth McNair (University of Melbourne), Michael Irwig (George Washington University, USA), the AusPATH executive committee, the ESA Medical Affairs Committee and the RACP Policy and Advocacy Committee for reviewing the manuscript. Ada Cheung is supported by an Australian Government National Health and Medical Research Council Early Career Fellowship (#1143333) and receives research support from the Viertel Charitable Foundation Clinical Investigator Award, an ESA Postdoctoral Award and the RACP Vincent Fairfax Family Foundation.

                    Competing interests:

                    No relevant disclosures.

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                      The risk of resistance: what are the major antimicrobial resistance threats facing Australia?

                      Deborah A Williamson, Benjamin P Howden and David L Paterson
                      Med J Aust 2019; 211 (3): . || doi: 10.5694/mja2.50249
                      Published online: 5 August 2019

                      Collaborative systems are required to combat the rising challenge of antimicrobial resistance in health care facilities and the community

                      These germs of disease have taken toll of humanity since the beginning of things—taken toll of our prehuman ancestors since life began here. But by virtue of this natural selection of our kind we have developed resisting power; to no germs do we succumb without a struggle …


                      • 1 Microbiological Diagnostic Unit Public Health Laboratory, Melbourne, VIC
                      • 2 Melbourne Health, Melbourne, VIC
                      • 3 Centre for Clinical Research, University of Queensland, Brisbane, QLD
                      • 4 Infectious Diseases Unit, Royal Brisbane and Women's Hospital, Brisbane, QLD


                      Acknowledgements: 

                      Deborah Williamson is supported by a National Health and Medical Research Council (NHMRC) Early Career Fellowship (GNT1123854). Benjamin Howden is supported by an NHMRC Practitioner Fellowship (GNT1105905).

                      Competing interests:

                      David Patterson has received research grants or honoraria for participation in advisory boards from Shionogi, MSD, Pfizer, Achaogen, Entasis Therapeutics and Accelerate Diagnostics.

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                      • 11. Klemm EJ, Shakoor S, Page AJ, et al. Emergence of an extensively drug‐resistant Salmonella enterica serovar Typhi clone harboring a promiscuous plasmid encoding resistance to fluoroquinolones and third‐generation cephalosporins. mBio 2018; 9: e00105–18.
                      • 12. Jennison AV, Whiley D, Lahra MM, et al. Genetic relatedness of ceftriaxone‐resistant and high‐level azithromycin resistant Neisseria gonorrhoeae cases, United Kingdom and Australia, February to April 2018. Euro Surveil 2019; 24: 1900118.
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