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    Increased incidence of community‐associated Staphylococcus aureus bloodstream infections in Victoria and Western Australia, 2011–2016

    Nabeel Imam, Simone Tempone, Paul K Armstrong, Rebecca McCann, Sandra Johnson, Leon J Worth and Michael J Richards
    Med J Aust 2019; 210 (2): . || doi: 10.5694/mja2.12057
    Published online: 21 January 2019

    Standardised national surveillance of health care‐associated Staphylococcus aureus bloodstream infections (HA‐SABs)1 has found that rates are declining in Australia.2 The incidence of community‐associated SABs (CA‐SABs), however, has not been investigated. These infections frequently have complicated courses (eg, metastatic sites of infection)3 and high mortality (about 20%).4

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      Nicotine and other potentially harmful compounds in “nicotine‐free” e‐cigarette liquids in Australia

      Emily Chivers, Maxine Janka, Peter Franklin, Benjamin Mullins and Alexander Larcombe
      Med J Aust 2019; 210 (3): . || doi: 10.5694/mja2.12059
      Published online: 14 January 2019

      Awareness and use of e‐cigarettes is increasing in Australia.1 The thousands of available e‐liquids contain various excipients, nicotine, flavourings, and other additives. There is little to no regulation of their manufacture, and potentially dangerous ingredients and incorrect nicotine levels have been identified.2 Of particular concern is the frequency with which nicotine is detected in e‐liquids labelled “nicotine‐free”.2 E‐liquids containing nicotine cannot legally be sold in Australia,3 but inaccurate labelling means that users may unwittingly inhale this addictive substance, or retailers may sell incorrectly labelled nicotine‐containing e‐liquids to willing customers. The aim of our investigation was to assess the chemical composition of a range of e‐liquids available in Australia, focusing on nicotine and other potentially harmful compounds. Formal ethics approval was not required for this study.

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


      Acknowledgements: 

      We acknowledge funding from the Australian Competition and Consumer Commission, Health Department of Western Australia, and from the National Health and Medical Research Council (APP1128231).

      Competing interests:

      No relevant disclosures.

      • 1. Yong HH, Borland R, Balmford J, et al. Trends in e‐cigarette awareness, trial, and use under the different regulatory environments of Australia and the United Kingdom. Nicotine Tob Res 2015; 17: 1203–1211.
      • 2. Trehy ML, Ye W, Hadwiger ME, et al. Analysis of electronic cigarette cartridges, refill solutions, and smoke for nicotine and nicotine related impurities. J Liq Chromatogr R T 2011; 34: 1442–1458.
      • 3. Douglas H, Hall W, Gartner C. E‐cigarettes and the law in Australia. Aust Fam Physician 2015; 44: 415–418.
      • 4. Goniewicz ML, Gupta R, Lee YH, et al. Nicotine levels in electronic cigarette refill solutions: a comparative analysis of products from the US, Korea, and Poland. Int J Drug Policy 2015; 26: 583–588.
      • 5. Abdel‐Gawad H, Hegazi B. Fate of 14C‐ethyl prothiofos insecticide in canola seeds and oils. J Environ Sci Health B 2010; 45: 116–122.
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        The Australasian Society of Clinical Immunology and Allergy infant feeding for allergy prevention guidelines

        Preeti A Joshi, Jill Smith, Sandra Vale and Dianne E Campbell
        Med J Aust 2019; 210 (2): . || doi: 10.5694/mja2.12102
        Published online: 14 January 2019

        Abstract

        Introduction: The Australasian Society of Clinical Immunology and Allergy, the peak professional body for clinical immunology and allergy in Australia and New Zealand, develops and provides information on a wide range of immune‐mediated disorders, including advice about infant feeding and allergy prevention for health professionals and families. Guidelines for infant feeding and early onset allergy prevention were published in 2016, with additional guidance published in 2017 and 2018, based on emerging evidence.

        Main recommendations:

        • When the infant is ready, at around 6 months, but not before 4 months, start to introduce a variety of solid foods. (This is not a strict window of introduction but rather a recommendation not to delay the introduction of solid foods beyond 12 months.)
        • Introduce peanut and egg in the first year of life in all infants, regardless of their allergy risk factors.
        • Hydrolysed (partially and extensively) formula is no longer recommended for the prevention of allergic disease.

         

        Changes in management a result of the guidelines: The guidelines specifically recommend introducing solid foods at around 6 months of age and introducing peanut and egg in the first year of life in all infants to prevent allergy development. Hydrolysed formula is no longer recommended for prevention of allergic disease. A new document outlining the reasons for and the method of peanut introduction to high risk infants is available for health professionals.


        • 1 Australasian Society of Clinical Immunology and Allergy, Sydney, NSW
        • 2 The Children's Hospital at Westmead, Sydney, NSW
        • 3 University of Sydney, Sydney, NSW


        Competing interests:

        Preeti Joshi is currently the chair of the ASCIA paediatric committee and the deputy chair of the National Allergy Strategy allergy prevention project. Sandra Vale is coordinator of the National Allergy Strategy. Jill Smith is the ASCIA CEO and company secretary. Dianne Campbell was chair of the ASCIA paediatric committee from 2011 to 2017, has received funding for unrelated research from the NHMRC, the Allergy and Immunology Foundation of Australasia and the Australian Food Allergy Foundation, and has received travel expenses to attend investigator meetings from DBV Technologies.

        • 1. Odhiambo JA, Williams HC, Clayton TO, et al. Global variations in prevalence of eczema symptoms in children from ISAAC Phase Three. J Allergy Clin Immunol 2009; 124: 1251–1258.e23.
        • 2. Prescott SL, Pawankar R, Allen KJ, et al. A global survey of changing patterns of food allergy burden in children. World Allergy Organ J 2013; 6: 21.
        • 3. Osborne NJ, Koplin JJ, Martin PE, et al. Prevalence of challenge‐proven IgE‐mediated food allergy using population‐based sampling and predetermined challenge criteria in infants. J Allergy Clin Immunol 2011; 127: 668–676.e2.
        • 4. Mullins RJ, Dear KB, Tang ML. Time trends in Australian hospital anaphylaxis admissions in 1998‐1999 to 2011‐2012. J Allergy Clin Immunol 2015; 136: 367–375.
        • 5. Mullins RJ, Wainstein BK, Barnes EH, et al. Increases in anaphylaxis fatalities in Australia from 1997 to 2013. Clin Exp Allergy 2016; 46: 1099–1110.
        • 6. Australasian Society of Clinical Immunology and Allergy. ASCIA guidelines – infant feeding and allergy prevention. Sydney: ASCIA, 2016. https://www.allergy.org.au/health-professionals/papers/infant-feeding-and-allergy-prevention (viewed Nov 2018).
        • 7. National Asthma Council Australia. Australian asthma handbook. Infant feeding and asthma prevention. http://www.asthmahandbook.org.au/prevention/primary/infant-feeding (viewed Nov 2018).
        • 8. BI Nwaru ME, S. Ahonen, M. Kaila, et al. Age at the introduction of solid foods during the first year and allergic sensitization at age 5 years. Pediatrics 2010; 125: 50–59.
        • 9. Netting MJ, Campbell DE, Koplin JJ, et al. An Australian consensus on infant feeding guidelines to prevent food allergy: outcomes from the Australian Infant Feeding Summit. J Allergy Clin Immunol Pract 2017; 5: 1617–1624.
        • 10. Grade Working Group. What is GRADE? http://www.gradeworkinggroup.org/ (viewed Nov 2018).
        • 11. Australasian Society of Clinical Immunology and Allergy. ASCIA guide for introduction of peanut to infants with severe eczema and/or food allergy. https://www.allergy.org.au/health-professionals/papers/ascia-guide-peanut-introduction (viewed Nov 2018).
        • 12. Du Toit G, Roberts G, Sayre PH, et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med 2015; 372: 803–813.
        • 13. Du Toit G, Katz Y, Sasieni P, et al. Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy. J Allergy Clin Immunol 2008; 122: 984–991.
        • 14. Kramer MS, Kakuma R. Maternal dietary antigen avoidance during pregnancy or lactation, or both, for preventing or treating atopic disease in the child. Cochrane Database Syst Rev 2012; (9): CD000133.
        • 15. Kramer MS, Kakuma R. Maternal dietary antigen avoidance during pregnancy or lactation, or both, for preventing or treating atopic disease in the child. Evid Based Child Health 2014; 9: 447–483.
        • 16. Gunaratne AW, Makrides M, Collins CT. Maternal prenatal and/or postnatal n‐3 long chain polyunsaturated fatty acids (LCPUFA) supplementation for preventing allergies in early childhood. Cochrane Database Syst Rev 2015; (7): CD010085.
        • 17. Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Vitamin and mineral supplementation and pregnancy. https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27sHealth/Statementandguidelines/Clinical-Obstetrics/Vitamin-andmineral-supplementation-in-pregnancy-(C-Obs-25)-Review-Nov-2014,-Amended-May-2015.pdf?ext=.pdf (viewed Nov 2018).
        • 18. United States Food and Drug Administration. Eating fish: what pregnant women and parents should know. https://www.fda.gov/Food/ResourcesForYou/Consumers/ucm393070.htm (viewed Nov 2018).
        • 19. Fiocchi A, Pawankar R, Cuello‐Garcia C, et al. World Allergy Organization‐McMaster University Guidelines for Allergic Disease Prevention (GLAD‐P): probiotics. World Allergy Organ J 2015; 8: 4.
        • 20. Foolad N, Brezinski EA, Chase EP, Armstrong AW. Effect of nutrient supplementation on atopic dermatitis in children: a systematic review of probiotics, prebiotics, formula, and fatty acids. JAMA Dermatol 2013; 149: 350–355.
        • 21. Osborn DA, Sinn JK. Probiotics in infants for prevention of allergic disease and food hypersensitivity. Cochrane Database Syst Rev 2007; (4): CD006475.
        • 22. National Health and Medical Research Council. Infant feeding guidelines: information for health workers. Canberra: NHMRC, 2012. https://www.nhmrc.gov.au/guidelines-publications/n56 (viewed Nov 2018).
        • 23. Victora CG, Bahl R, Barros AJ, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet 2016; 387: 475–490.
        • 24. Grimshaw K, Logan K, O'Donovan S, et al. Modifying the infant's diet to prevent food allergy. Arch Dis Child 2017; 102: 179–186.
        • 25. Osborn DA, Sinn J. Soy formula for prevention of allergy and food intolerance in infants. Cochrane Database Syst Rev 2006; (4): CD003741.
        • 26. Boyle RJ, Ierodiakonou D, Khan T, et al. Hydrolysed formula and risk of allergic or autoimmune disease: systematic review and meta‐analysis. BMJ 2016; 352: i974.
        • 27. Osborn DA, Sinn J. Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants. Cochrane Database Syst Rev 2006; (4): CD003664.
        • 28. Osborn DA, Sinn JK, Jones LJ. WITHDRAWN: Infant formulas containing hydrolysed protein for prevention of allergic disease and food allergy. Cochrane Database Syst Rev 2017; (5): CD003664.
        • 29. von Berg A, Filipiak‐Pittroff B, Schulz H, et al. Allergic manifestation 15 years after early intervention with hydrolyzed formulas–the GINI Study. Allergy 2016; 71: 210–219.
        • 30. Australasian Society of Clinical Immunology and Allergy. ASCIA information on how to introduce solid foods to babies for allergy prevention. https://www.allergy.org.au/patients/allergy-prevention/ascia-how-to-introduce-solid-foods-to-babies (viewed Nov 2018).
        • 31. Perkin MR, Logan K, Tseng A, et al. Randomized trial of introduction of allergenic foods in breast‐fed infants. N Engl J Med 2016; 374: 1733–1743.
        • 32. Fleischer DM, Spergel JM, Assa'ad AH, Pongracic JA. Primary prevention of allergic disease through nutritional interventions. J Allergy Clin Immunol Pract 2013; 1: 29–36.
        • 33. FR Greer SHS, A. W Burks. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas Pediatrics 2008; 121: 183–191.
        • 34. Muraro A, Halken S, Arshad SH, et al. EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy. Allergy 2014; 69: 590–601.
        • 35. World Health Organization. Global strategy on infant and young child feeding. Geneva: WHO, 2003. https://www.who.int/nutrition/topics/infantfeeding_recommendation/en/ (viewed Nov 2018).
        • 36. Palmer DJ, Sullivan TR, Gold MS, et al. Randomized controlled trial of early regular egg intake to prevent egg allergy. J Allergy Clin Immunol 2017; 139:1600–1607.e2.
        • 37. Perkin MR, Lack G. Introducing allergenic foods in infants. N Engl J Med 2016; 375: e16.
        • 38. Du Toit G, Roberts G, Sayre PH, et al. Identifying infants at high risk of peanut allergy: the Learning Early About Peanut Allergy (LEAP) screening study. J Allergy Clin Immunol 2013; 131: 135–143.e12.
        • 39. Du Toit G, Sayre PH, Roberts G, et al. Effect of avoidance on peanut allergy after early peanut consumption. N Engl J Med 2016; 374: 1435–1443.
        • 40. Togias A, Cooper SF, Acebal ML, et al. Addendum guidelines for the prevention of peanut allergy in the United States: report of the National Institute of Allergy and Infectious Diseases‐sponsored expert panel. J Allergy Clin Immunol 2017; 139: 29–44.
        • 41. Turner PJ, Campbell DE, Boyle RJ, Levin ME. Primary prevention of food allergy: translating evidence from clinical trials to population‐based recommendations. J Allergy Clin Immunol Pract 2018; 6: 367–375.
        • 42. Turner PJ CD. Implementing primary prevention for peanut allergy at a population level. JAMA 2017; 317: 1111–1112.
        • 43. Levin M, Goga A, Doherty T, et al. Allergy and infant feeding guidelines in the context of resource‐constrained settings. J Allergy Clin Immunol 2017; 139: 455–458.
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          Baby boomers and booze: we should be worried about how older Australians are drinking

          Ann M Roche and Victoria Kostadinov
          Med J Aust 2019; 210 (1): . || doi: 10.5694/mja2.12025
          Published online: 14 January 2019

          Alcohol research has traditionally focused on younger age groups; consumption patterns and predictors for older people have received only limited attention. However, the number of older Australians has increased substantially in recent years, accompanied by unprecedented changes in their alcohol consumption patterns. Older people are vulnerable to a range of alcohol‐related adverse effects, including falls and other injuries, diabetes, cardiovascular disease, cancer, mental health problems, obesity, liver disease, and early onset dementia and other brain injury.1,2,3 These vulnerabilities are a cause for clinical concern.

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          • National Centre for Education and Training on Addiction, Flinders University, Adelaide, SA


          Correspondence: ann.roche@flinders.edu.au
          Competing interests:

          No relevant disclosures.

          • 1. Crome I, Dar K, Janikiewicz S, et al. Our invisible addicts: first report of the Older Persons’ Substance Misuse Working Group of the Royal College of Psychiatrists. Second edition (College Report CR211). London: Royal College of Psychiatrists, 2018. https://www.rcpsych.ac.uk/files/pdfversion/CR211.pdf (viewed Aug 2018).
          • 2. Scoccianti C, Cecchini M, Anderson AS, et al. European Code against Cancer 4th edition. Alcohol drinking and cancer. Cancer Epidemiol 2015; 39: S67–S74.
          • 3. Schwarzinger M, Pollock BG, Hasan OSM, et al. Contribution of alcohol use disorders to the burden of dementia in France 2008–13: a nationwide retrospective cohort study. Lancet Public Health 2018; 3: e124–e132.
          • 4. Australian Institute of Health and Welfare. National drug strategy household survey 2016: detailed findings. Canberra: AIHW, 2017. https://www.aihw.gov.au/reports/illicit-use-of-drugs/2016-ndshs-detailed/data (viewed Sept 2018).
          • 5. National Health and Medical Research Council. Australian guidelines to reduce health risks from drinking alcohol (Cat. No. DS10). Canberra: NHMRC, 2009. https://www.nhmrc.gov.au/guidelines-publications/ds10 (viewed Sept 2018).
          • 6. Wadd S, Lapworth K, Sullivan M, et al. Working with older drinkers. Bedford: Tilda Goldberg Centre, University of Bedfordshire, 2011. http://alcoholresearchuk.org/downloads/finalReports/FinalReport_0085 (viewed Aug 2018).
          • 7. Barry KL, Blow FC. Drinking over the lifespan: focus on older adults. Alcohol Res 2016; 38: 115–120.
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            Screening for perinatal depression and predictors of underscreening: findings of the Born in Queensland study

            Macarena A San Martin Porter, Kim Betts, Steve Kisely, Gino Pecoraro and Rosa Alati
            Med J Aust 2019; 210 (1): . || doi: 10.5694/mja2.12030
            Published online: 14 January 2019

            Abstract

            Objectives: To investigate screening with the Edinburgh Postnatal Depression Scale (EPDS) as part of Queensland prenatal care services, as well as maternal and socio‐demographic factors associated with not being screened.

            Design, setting: Cross‐sectional retrospective analysis of data from the Queensland population‐based Perinatal Data Collection for July 2015 – December 2015.

            Participants: All women giving birth in Queensland during the second half of 2015.

            Main outcome measures: Screening with the EPDS, with the values “yes” (health professional recorded an EPDS score), “no” (health professional reported it was not performed), and “not stated”.

            Results: Of 30 468 women who gave birth in Queensland, 21 735 (71.3%) completed the EPDS during pregnancy; 18 942 pregnant women were enrolled as public patients (91.0%) and 2762 as private patients (28.8%). After adjusting for other socio‐demographic factors, screening was less likely for women who were aged 36 years or more (v 25 years or younger: adjusted odds ratio [OR], 0.69; 95% CI, 0.60–0.79), enrolled as private patients (aOR, 0.05; 95% CI, 0.05–0.06), born overseas (aOR, 0.75; 95% CI, 0.68–0.82), Indigenous Australians (aOR, 0.47; 95% CI, 0.39–0.56), single or separated (aOR, 0.83; 95% CI, 0.73–0.94), or of higher socio‐economic status.

            Conclusions: Four years after clinical guidelines recommending universal screening with the EPDS were published, screening rates for private and public health care patients differed markedly. Our results may inform future comparisons and analyses of the impact on screening of recent changes to Medicare definitions intended to increase that of women in private health care.

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            • 1 Institute for Social Science Research, University of Queensland, Brisbane, QLD
            • 2 University of Queensland, Brisbane, QLD
            • 3 Curtin University, Perth, WA


            Correspondence: m.sanmartinporter@uq.edu.au
            Competing interests:

            No relevant disclosures.

            • 1. Australian Institute of Health and Welfare. Australia's mothers and babies 2015: in brief (Perinatal statistics series no. 33; Cat no. PER 91). Canberra: AIHW. 2017.
            • 2. Gavin NI, Gaynes BN, Lohr KN, et al. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol 2005; 106: 1071–1083.
            • 3. Dennis C‐L, Falah‐Hassani K, Shiri R. Prevalence of antenatal and postnatal anxiety: systematic review and meta‐analysis. Br J Psychiatry 2018; 210: 315–323.
            • 4. Eastwood J, Ogbo F, Hendry A, et al. The impact of antenatal depression on perinatal outcomes in Australian women. PLoS One 2017; 12: e0169907.
            • 5. Leigh B, Milgrom J. Risk factors for antenatal depression, postnatal depression and parenting stress. BMC Psychiatry 2008; 8: 24.
            • 6. Gentile S. Untreated depression during pregnancy: short‐ and long‐term effects in offspring. A systematic review. Neuroscience 2017; 342: 154–166.
            • 7. Kingston D, Austin MP, Heaman M, et al. Barriers and facilitators of mental health screening in pregnancy. J Affect Disord 2015; 186: 350–357.
            • 8. Buist A. National program for depression associated with childbirth: the Australian experience. Best Pract Res Clin Obstet Gynaecol 2007; 21: 193–206.
            • 9. Austin MP, Kingston D. Psychosocial assessment and depression screening in the perinatal period: benefits, challenges and implementation. In: Sutter‐Dallay AL, Glangeaud‐Freudenthal NMC, Guedeney A, Riecher‐Rössler A, editors. Joint care of parents and infants in perinatal psychiatry. Cham: Springer International Publishing, 2016; pp. 167–195.
            • 10. O'Connor E, Rossom RC, Henninger M, et al. Primary care screening for and treatment of depression in pregnant and postpartum women: evidence report and systematic review for the US Preventive Services Task Force. JAMA 2016; 315: 388–406.
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            • 12. Austin M‐P, Highet N. Depression and related disorders — anxiety, bipolar disorder and puerperal psychosis — in the perinatal period. A guideline for primary care health professionals providing care in the perinatal period. Melbourne: beyondblue, 2011. http://resources.beyondblue.org.au/prism/file?token=BL/0891 (viewed Jan 2018).
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            • 15. Australian Institute of Health and Welfare. Perinatal depression: data from the 2010 Australian National Infant Feeding Survey (Cat. No PHE 161). Canberra: AIHW, 2012.
            • 16. Reilly N, Harris S, Loxton D, et al. Disparities in reported psychosocial assessment across public and private maternity settings: a national survey of women in Australia. BMC Public Health 2013; 13: 632.
            • 17. Yelland J, Brown SJ. Asking women about mental health and social adversity in pregnancy: results of an Australian population‐based survey. Birth 2014; 41: 79–87.
            • 18. Betts KS, Soares Magalhaes RJ, Alati R. The role of neonatal pulmonary morbidity in the longitudinal patterns of hospitalisation for respiratory infection during the first year of life. Epidemiol Infect 2018; 146: 1–8.
            • 19. Australian Bureau of Statistics. 1270.0.55.005. Australian Statistical Geography Standard (ASGS): volume 5. Remoteness structure 2016. http://www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/1270.0.55.005Main%20Features1July%202016?opendocument&tabname=Summary&prodno=1270.0.55.005&issue=July%202016&num=&view= (viewed Feb 2018).
            • 20. Pink B. Socio‐Economic Indexes for Areas (SEIFA) 2011: technical paper. Mar 2013. http://www.ausstats.abs.gov.au/Ausstats/subscriber.nsf/0/22CEDA8038AF7A0DCA257B3B00116E34/$File/2033.0.55.001%20seifa%202011%20technical%20paper.pdf (viewed Feb 2018).
            • 21. Kohlhoff J, Hickinbotham R, Knox C, et al. Antenatal psychosocial assessment and depression screening in a private hospital. Aust N Z J Obstet Gynaecol 2016; 56: 173–178.
            • 22. Ogbo FA, Eastwood J, Hendry A, et al. Determinants of antenatal depression and postnatal depression in Australia. BMC Psychiatry 2018; 18: 49.
            • 23. Leddy MA, Lawrence H, Schulkin J. Obstetrician‐gynecologists and women's mental health: findings of the Collaborative Ambulatory Research Network 2005–2009. Obstet Gynecol Surv 2011; 66: 316–323.
            • 24. Kingston D, Austin M‐P, McDonald SW, et al. Pregnant women's perceptions of harms and benefits of mental health screening. PLoS One 2015; 10: e0145189.
            • 25. Australian Government Department of Health. Changes to MBS Items for obstetrics services. Updated Oct 2017. http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Factsheet-ObstetricsServices (viewed Feb 2018).
            • 26. Austin MP, Highet N, the Expert Working Group. Mental health care in the perinatal period: Australian clinical practice guideline. Melbourne: Centre of Perinatal Excellence, 2017. http://cope.org.au/wp-content/uploads/2018/05/COPE-Perinatal-MH-Guideline_Final-2018.pdf (viewed Feb 2018).
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              Access to rehabilitation for patients with stroke in Australia

              Elizabeth A Lynch, Shylie Mackintosh, Julie A Luker and Susan L Hillier
              Med J Aust 2019; 210 (1): . || doi: 10.5694/mja2.12034
              Published online: 14 January 2019

              Abstract

              Objective: To identify factors associated with receiving acute goal‐directed treatment, being assessed for ongoing rehabilitation, and receiving post‐acute rehabilitation after having a stroke.

              Design: Retrospective analysis of National Stroke Audit data for patients with acute stroke treated at Australian hospitals during 1 September 2014 – 28 February 2015.

              Setting, participants: 112 Australian hospitals that admit adults with acute stroke.

              Main outcomes: Associations between patient‐related and organisational factors and the provision of rehabilitation interventions.

              Results: Data for 3462 patients were eligible for analysis; their median age was 74 years, 1962 (57%) were men, and 2470 (71%) had received care in a stroke unit. 2505 patients (72%) received goal‐directed treatment during their acute admission; it was not provided to 364 patients (10.5%) who were responsive, had not fully recovered, and did not refuse treatment. Factors associated with higher odds of receiving goal‐directed treatment included goal‐setting with the patient and their family (odds ratio [OR], 6.75; 95% CI, 5.07–8.90) and receiving care in a stroke unit (OR, 2.08; 95% CI, 1.61–2.70). 1358 patients (39%) underwent further rehabilitation after discharge from acute care; factors associated with receiving post‐acute rehabilitation included care in a stroke unit (OR, 1.73; 95% CI, 1.34–2.22) and having an arm or speech deficit. Dementia was associated with lower odds of receiving acute goal‐directed treatment (OR, 0.49; 95%, 0.33–0.73) and post‐acute rehabilitation (OR, 0.43; 95%, 0.30–0.61).

              Conclusions: Access to stroke units and to early and ongoing rehabilitation for patients after stroke can be improved in Australia, both to optimise outcomes and to reduce the burden of care on underresourced community and primary care providers.

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              • 1 Adelaide Nursing School, University of Adelaide, Adelaide, SA
              • 2 NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne, VIC
              • 3 Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC
              • 4 University of South Australia, Adelaide, SA


              Acknowledgements: 

              Elizabeth Lynch is supported by a National Health and Medical Research Council (NHMRC) Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery grant (1077898) and an NHMRC Early Career Fellowship (1138515). The audit data, initially collected with the Australian Stroke Data Tool (AuSDaT), were provided by the Stroke Foundation of Australia. We thank Kelvin Hill for valuable feedback when reviewing drafts of the manuscript.

              Competing interests:

              No relevant disclosures.

              • 1. Pollock A, Baer G, Campbell P, et al. Physical rehabilitation approaches for the recovery of function and mobility following stroke. Cochrane Database Syst Rev 2014; (4): CD001920.
              • 2. Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev 2013; (9): CD000197.
              • 3. Pereira S, Ross Graham J, Shahabaz A, et al. Rehabilitation of individuals with severe stroke: synthesis of best evidence and challenges in implementation. Top Stroke Rehabil 2012; 19: 122–131.
              • 4. Langhorne P, Bernhardt J, Kwakkel G. Stroke rehabilitation. Lancet 2011; 377: 1693–1702.
              • 5. Lynch E, Hillier S, Cadilhac D. When should physical rehabilitation commence after stroke: a systematic review. Int J Stroke 2014; 9: 468–478.
              • 6. Lynch EA, Luker JA, Cadilhac D, Hillier SL. Inequities in access to inpatient rehabilitation after stroke: an international scoping review. Top Stroke Rehabil 2017; 24: 619–626.
              • 7. Stroke Foundation. Clinical guidelines for stroke management 2017. Aug 2017. https://informme.org.au/Guidelines/Clinical-Guidelines-for-Stroke-Management-2017 (viewed Dec 2017).
              • 8. Lynch EA, Luker JA, Cadilhac DA, Hillier SL. Rehabilitation assessments for patients with stroke in Australian hospitals do not always reflect the patients’ rehabilitation requirements. Arch Phys Med Rehabil 2015; 96: 782–789.
              • 9. Bayley MT, Hurdowar A, Richards CL, et al. Barriers to implementation of stroke rehabilitation evidence: findings from a multi‐site pilot project. Disabil Rehabil 2012; 34: 1633–1638.
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              • 12. Hakkennes S, Hill KD, Brock K, et al. Selection for inpatient rehabilitation after severe stroke: what factors influence rehabilitation assessor decision‐making? J Rehabil Med 2013; 45: 24–31.
              • 13. Cruz‐Flores S, Rabinstein A, Biller J, et al. Racial‐ethnic disparities in stroke care: the American experience. A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011; 42: 2091–2116.
              • 14. Ivers N, Jamtvedt G, Flottorp S, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012; (13): CD000259.
              • 15. National Stroke Foundation. Acute audits. https://informme.org.au/en/stroke-data/Acute-audits (viewed Dec 2017).
              • 16. Australian Stroke Coalition Rehabilitation Working Group. Assessment for rehabilitation: pathway and decision‐making tool 2012. Melbourne: Stroke Foundation, 2012. https://strokefoundation.org.au/-/media/C7FB61819D30442FA9A5C63F42ADB167.ashx?la=en (viewed Dec 2017).
              • 17. Luker JA, Bernhardt J, Grimmer K, Edwards I. A qualitative exploration of discharge destination as an outcome or a driver of acute stroke care. BMC Health Serv Res 2014; 14: 193.
              • 18. Crocker T, Forster A, Young J, et al. Physical rehabilitation for older people in long‐term care. Cochrane Database Syst Rev 2013; (2): CD004294.
              • 19. Cadilhac DA, Andrew NE, Kilkenny MF, et al. Improving quality and outcomes of stroke care in hospitals: protocol and statistical analysis plan for the Stroke 123 implementation study. Int J Stroke 2018; 13: 96–106.
              • 20. Foster A, Worrall L, Rose M, O'Halloran R. “I do the best I can”: an in‐depth exploration of the aphasia management pathway in the acute hospital setting. Disabil Rehabil 2016; 38: 1765–1779.
              • 21. Tellier M, Rochette A. Falling through the cracks: a literature review to understand the reality of mild stroke survivors. Top Stroke Rehabil 2009; 16: 454–462.
              • 22. Edwards D, Hahn M, Baum C, et al. Screening patients with stroke for rehabilitation needs: validation of the post‐stroke rehabilitation guidelines. Neurorehabil Neural Repair 2006; 20: 42–48.
              • 23. Paker N, Buğdaycı D, Tekdöş D, et al. Impact of cognitive impairment on functional outcome in stroke. Stroke Res Treat 2010; 2010: 1–5.
              • 24. Moyle W, Borbasi S, Wallis M, et al. Acute care management of older people with dementia: a qualitative perspective. J Clin Nurs 2011; 20: 420–428.
              • 25. Brodaty H, Draper B, Low LF. Behavioural and psychological symptoms of dementia: a seven‐tiered model of service delivery. Med J Aust 2003; 178: 231–234. https://www.mja.com.au/journal/2003/178/5/behavioural-and-psychological-symptoms-dementia-seven-tiered-model-service
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                Regulatory and other responses to the pharmaceutical opioid problem

                Gabrielle Campbell, Nicholas Lintzeris, Natasa Gisev, Briony Larance, Sallie Pearson and Louisa Degenhardt
                Med J Aust 2019; 210 (1): . || doi: 10.5694/mja2.12047
                Published online: 12 December 2018

                How is Australia responding to the trends in pharmaceutical opioid utilisation and opioid harms?

                In the past 20 years, there have been substantial increases in the use of pharmaceutical opioids in many countries including Australia, which has one of the highest levels of opioid utilisation globally.1 Almost 15 million opioid prescriptions were dispensed in 2015 and our use of high potency opioids has also increased.2 One of the main drivers is the higher use of prescription opioids for chronic non‐cancer pain (CNCP).3 In parallel to escalating use, opioid‐related harms have also increased. Since 2000, there has been a shift in hospitalisations due to opioid poisonings and opioid‐related deaths from predominantly heroin to pharmaceutical opioids.4 Extramedical use — defined as any use of a medication outside the formal medical system or inconsistent with a doctor's prescription5 — is also relatively common; the most recent household survey indicates that “non‐medical use” was reported by 4.8% of the Australian population.4


                • 1 National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW
                • 2 University of Sydney, Sydney, NSW
                • 3 Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, NSW
                • 4 University of Wollongong, Wollongong, NSW
                • 5 Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW
                • 6 Menzies Centre for Health Policy, University of Sydney, Sydney, NSW


                Correspondence: G.Campbell@unsw.edu.au
                Acknowledgements: 

                Gabrielle Campbell, Natasa Gisev, Briony Larance and Louisa Degenhardt are supported by National Health and Medical Research Council fellowships (No. 1119992, 1091878, 1073858, and 1135991). The National Drug and Alcohol Research Centre at the University of New South Wales is supported by funding from the Australian Government under the Substance Misuse Prevention and Service Improvements Grant Fund.

                Competing interests:

                Some of the authors have received investigator‐initiated untied educational grants from Reckitt Benckiser and Indivior for studies of buprenorphine–naloxone (Briony Larance, Louisa Degenhardt and Nicholas Lintzeris), buprenorphine depot (Briony Larance, Louisa Degenhardt and Nicholas Lintzeris), naloxone (Louisa Degenhardt), the development of an opioid‐related behaviour scale (Briony Larance, Louisa Degenhardt and Nicholas Lintzeris), projects regarding opioid dependence treatment (Nicholas Lintzeris), and a study of opioid substitution therapy uptake among patients with CNCP (Briony Larance, Louisa Degenhardt, Gabrielle Campbell and Nicholas Lintzeris). Louisa Degenhardt and Briony Larance have also received an untied educational grant from Seqirus for studies of tapentadol. None of these are directly relevant to the current manuscript.

                • 1. Berterame S, Erthal J, Thomas J, et al. Use of and barriers to access to opioid analgesics: a worldwide, regional, and national study. Lancet 2016; 387: 1644–1656.
                • 2. Karanges EA, Blanch B, Buckley NA, Pearson SA. Twenty‐five years of prescription opioid use in Australia: a whole‐of‐population analysis using pharmaceutical claims. Br J Clin Pharmacol 2016; 82: 255–267.
                • 3. Kolodny A, Courtwright DT, Hwang CS, et al. The prescription opioid and heroin crisis: a public health approach to an epidemic of addiction. Annu Rev Public Health 2015; 36: 559–574.
                • 4. Australian Institute of Health and Welfare. Non‐medical use of pharmaceuticals: trends, harms and treatment, 2006–07 to 2015–16. (Drug treatment series no. 30. Cat. No. HSE 195) Canberra: AIHW; 2017. https://www.aihw.gov.au/reports/illicit-use-of-drugs/non-medical-use-pharmaceuticals/contents/table-of-contents (viewed Nov 2018).
                • 5. Larance B, Degenhardt L, Lintzeris N, et al. Definitions related to the use of pharmaceutical opioids: extramedical use, diversion, non‐adherence and aberrant medication‐related behaviours. Drug Alcohol Rev 2011; 30: 236–245.
                • 6. National Drug Strategy. National Pharmaceutical Drug Misuse Framework for Action (2012–2015). Commonwealth of Australia; 2012. http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/Publishing.nsf/content/drug-mu-frm-action (viewed Nov 2018).
                • 7. Cairns R, Brown JA, Buckley NA. The impact of codeine re‐scheduling on misuse: a retrospective review of calls to Australia's largest poisons centre. Addiction 2016; 111: 1848–1853.
                • 8. Schug SA, Dobbin MD, Pilgrim JL. Caution with the forthcoming rescheduling of over‐the‐counter codeine‐containing analgesics. Med J Aust 2018; 208: 51–52. https://www.mja.com.au/journal/2018/208/1/caution-forthcoming-rescheduling-over-counter-codeine-containing-analgesics
                • 9. Therapeutic Goods Administration. Prescription strong (Schedule 8) opioid use and misuse in Australia — options for a regulatory response. Consultation paper. Canberra: Commonwealth of Australia; 2018. https://www.tga.gov.au/sites/default/files/consultation-prescription-strong-schedule-8-opiod-use-misuse-in-australia-options-for-regulatory-response.pdf (viewed Nov 2018).
                • 10. Fink DS, Schleimer JP, Sarvet A, et al. Association between prescription drug monitoring programs and nonfatal and fatal drug overdoses. Ann Intern Med 2018; 168: 783–790.
                • 11. Pauly NJ, Slavova S, Delcher C, et al. Features of prescription drug monitoring programs associated with reduced rates of prescription opioid‐related poisonings. Drug Alcohol Depend 2018; 184: 26–32.
                • 12. Islam MM, McRae IS. An inevitable wave of prescription drug monitoring programs in the context of prescription opioids: pros, cons and tensions. BMC Pharmacol Toxicol 2014; 15: 46.
                • 13. Peacock A, Degenhardt L, Hordern A, et al. Methods and predictors of tampering with a tamper‐resistant controlled‐release oxycodone formulation. Int J Drug Policy 2015; 26: 1265–1272.
                • 14. Larance B, Lintzeris N, Ali R, et al. The diversion and injection of a buprenorphine‐naloxone soluble film formulation. Drug Alcohol Depend 2014; 136: 21–27.
                • 15. Larance B, Dobbins T, Peacock A, et al. The effect of a potentially tamper‐resistant oxycodone formulation on opioid use and harm: main findings of the National Opioid Medications Abuse Deterrence (NOMAD) study. Lancet Psychiatry 2018; 5: 155–166.
                • 16. Therapeutic Guidelines. Analgesic: therapeutic guidelines. Melbourne: eTG Complete; 2018. https://tgldcdp.tg.org.au/etgcomplete (viewed Nov 2018).
                • 17. Hogg MN, Gibson S, Helou A, et al. Waiting in pain: a systematic investigation into the provision of persistent pain services in Australia. Med J Aust 2012; 196: 386–390. https://www.mja.com.au/journal/2012/196/6/waiting-pain-systematic-investigation-provision-persistent-pain-services
                • 18. Larance B, Campbell G, Moore T, et al. Concerns and help‐seeking among patients using opioids for management of chronic noncancer pain. Pain Med 2018; https://doi.org/10.1093/pm/pny078 [Epub ahead of print].
                • 19. Nielsen S, Larance B, Degenhardt L, et al. Opioid agonist treatment for pharmaceutical opioid dependent people. Cochrane Database Syst Rev 2016; (5): CD011117.
                • 20. Nielsen S, Larance B, Lintzeris N. Opioid agonist treatment for patients with dependence on prescription opioids. JAMA 2017; 317: 967–968.
                • 21. Worley MJ, Heinzerling KG, Shoptaw S, Ling W. Pain volatility and prescription opioid addiction treatment outcomes in patients with chronic pain. Exp Clin Psychopharmacol 2015; 23: 428–435.
                • 22. Holliday S, Magin P, Oldmeadow C, et al. An examination of the influences on New South Wales general practitioners regarding the provision of opioid substitution therapy. Drug Alcohol Rev 2013; 32: 495–503.
                • 23. Scarborough J, Eliott J, Braunack‐Mayer A. Opioid substitution therapy — a study of GP participation in prescribing. Aust Fam Physician 2011; 40: 241–245.
                • 24. Hotham E, Roche A, Skinner N, Dollman B. The general practitioner pharmacotherapy prescribing workforce: examining sustainability from a systems perspective. Drug Alcohol Rev 2005; 24: 393–400.
                • 25. Longman C, Lintzeris N, Temple‐Smith M, Gilchrist G. Methadone and buprenorphine prescribing patterns of Victorian general practitioners: Their first 5 years after authorisation. Drug Alcohol Rev 2011; 30: 355–359.
                • 26. Dwyer R, Olsen A, Fowlie C, et al. An overview of take‐home naloxone programs in Australia. Drug Alcohol Rev 2018; 37: 440–449.
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                  Licence to swill: James Bond’s drinking over six decades

                  Nick Wilson, Anne Tucker, Deborah Heath and Peter Scarborough
                  Med J Aust 2018; 209 (11): . || doi: 10.5694/mja18.00947
                  Published online: 10 December 2018

                  Abstract

                  Objectives: To describe the patterns of alcohol use in James Bond movies over six decades.

                  Design: Film content analysis.

                  Setting: Wide range of international locations in 24 James Bond movies (Eon Productions series, 1962–2015).

                  Main outcome measures: Drinking episodes for Bond and major female characters; alcohol product placement in films; peak estimated blood alcohol concentrations; features relevant to DSM-5 criteria for alcohol use disorder.

                  Results: Bond has drunk heavily and consistently across six decades (109 drinking events; mean, 4.5 events per movie). His peak blood alcohol level was estimated to have been 0.36 g/dL, sufficient to kill some people. We classified him as having severe alcohol use disorder, as he satisfied six of 11 DSM-5 criteria for this condition. Chronic risks for Bond include frequently drinking prior to fights, driving vehicles (including in chases), high stakes gambling, operating complex machinery or devices, contact with dangerous animals, extreme athletic performance, and sex with enemies, sometimes with guns or knives in the bed. Notable trends during the study period included a decline in using alcohol as a weapon (P = 0.023) and an increase in the number of alcohol products in his environment (for alcohol-related product placement: P < 0.001), but his martini consumption has been steady. Drinking by lead female characters and a random selection of 30 of his sexual partners was fairly stable over time, but also occasionally involved binges.

                  Conclusions: James Bond has a severe chronic alcohol problem. He should consider seeking professional help and find other strategies for managing on-the-job stress.

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                  • 1 University of Otago, Wellington, New Zealand
                  • 2 Wellington, New Zealand
                  • 3 Te Aka Kura, Hamilton, New Zealand
                  • 4 Oxford University, Oxford, United Kingdom


                  Correspondence: nick.wilson@otago.ac.nz
                  Competing interests:

                  No relevant disclosures.

                  • 1. Wilson N, Tucker A. Die Another Day, James Bond’s smoking over six decades. Tob Control 2016; 26: 489-490.
                  • 2. McAnally HM, Robertson LA, Strasburger VC, Hancox RJ. Bond, James Bond: a review of 46 years of violence in films. JAMA Pediatr 2013; 167: 195-196.
                  • 3. Alrutz AS, Kool B, Robinson T, et al. The psychopathology of James Bond and its implications for the revision of the DSM-(00)7. Med J Aust 2015; 203: 452-456. <MJA full text>
                  • 4. Jonason PK, Webster GD, Schmitt DP, et al. The antihero in popular culture: life history theory and the dark triad personality traits. Rev Gen Psychol 2012; 16: 192-199.
                  • 5. Neuendorf K, Gore K, Dalessandro A, et al. Shaken and stirred: a content analysis of women’s portrayals in James Bond films. Sex Roles 2010; 62: 747-761.
                  • 6. Croley JA, Reese V, Wagner RF. Dermatologic features of classic movie villains: the face of evil. JAMA Dermatol 2017; 153: 559-564.
                  • 7. Johnson G, Guha IN, Davies P. Were James Bond’s drinks shaken because of alcohol induced tremor? BMJ 2013; 347: f7255.
                  • 8. Wikipedia. James Bond in film. Updated Sept 2018. https://en.wikipedia.org/wiki/James_Bond_in_film (viewed Sept 2018).
                  • 9. Leigh D. James Bond drinks: the complete guide to the drinks of James Bond, 2nd edition. Amazon Digital Services, 2012.
                  • 10. Andersson A, Wirehn AB, Olvander C, et al. Alcohol use among university students in Sweden measured by an electronic screening instrument. BMC Public Health 2009; 9: 229.
                  • 11. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, Fifth edition (DSM-5). Arlington (VA): American Psychiatric Association, 2013.
                  • 12. Jones S. James Bond product placement: the definitive timeline of brands in Bond [online]. Hollywood Branded [website]. 14 May 2018. http://blog.hollywoodbranded.com/blog/james-bond-product-placement-the-definitive-timeline-of-brands-in-bond (viewed Sept 2018).
                  • 13. AlcoholAlert! Blood Alcohol Level and You [webpage]. 2017. http://www.alcoholalert.com/blood-alcohol-level.html (viewed Sept 2018).
                  • 14. Afshar M, Netzer G, Salisbury-Afshar E, et al. Injured patients with very high blood alcohol concentrations. Injury 2016; 47: 83-88.
                  • 15. Schlueter N, Tveit AB. Prevalence of erosive tooth wear in risk groups. Monogr Oral Sci 2014; 25: 74-98.
                  • 16. Ponsford J, Tweedly L, Taffe J. The relationship between alcohol and cognitive functioning following traumatic brain injury. J Clin Exp Neuropsychol 2013; 35: 103-112.
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                    The emergence and characteristics of the Australian Mamil

                    Adrian E Bauman, Katrina Blazek, Lindsey Reece and William Bellew
                    Med J Aust 2018; 209 (11): . || doi: 10.5694/mja18.00841
                    Published online: 10 December 2018

                    Abstract

                    Background: The Mamil (middle-aged man in Lycra) appears to be an emergent cycling-focused species.

                    Objectives: To explore the nature and distribution of the Mamilian species; to determine whether rates of cycling by middle-aged men in Australia have changed since the pre-Mamilian era.

                    Setting: Secondary analysis of representative population-based datasets. National sport participation data from the Exercise, Recreation and Sport (2002–2004, 2008–2010) and Ausplay surveys (2016) were analysed to assess trends in recreational and exercise-related cycling, including by middle-aged men (45–64 years of age). Data from New South Wales Population Health Surveys (2006, 2010, 2014) and Australian censuses (2006, 2011, 2014) were analysed to assess trends in cycling to work.

                    Main outcome measures: Cycling participation rates (at least once or at least once a week in the past 12 months); rates of cycling to work.

                    Results: The proportion of middle-aged men who cycled for exercise or recreational purposes at least once a week during the previous year increased from 6.2% (95% CI, 5.5–7.0%) during 2002–2004 to 13.2% (95% CI, 11.9–14.6%) in 2016. The prevalence of Mamils in the most affluent residential areas has more than doubled since 2002–2004, and is twice as high as in the least advantaged locations. Media reports of “Mamils” corroborate these temporal trends.

                    Discussion: Mamils in Australia are socially graded, and also grade themselves according to bicycle-related expenditure and hill gradients overcome. They often form cohesive and supportive groups, but may not reflect a population-wide social movement to increase physical activity among adult Australians.

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                    • 1 University of Sydney, Sydney, NSW
                    • 2 New South Wales Ministry of Health, Sydney, NSW


                    Correspondence: adrian.bauman@sydney.edu.au
                    Acknowledgements: 

                    This work was completed while Katrina Blazek was employed as a trainee in the NSW Biostatistics Training Program funded by the NSW Ministry of Health. She undertook this work while based at the Prevention Research Collaboration, Charles Perkins Centre at the School of Public Health, the University of Sydney. We thank several (medically) “specialised” Mamils who provided anonymous source material.

                    Competing interests:

                    Between us, we own up to having four functional bicycles, with a total value of no more than $1200, substantially less than that of a single set of the Mavic Aksium wheels often seen on Mamilian bicycles.

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                      Adding kindness at handover to improve our collegiality: the K-ISBAR tool

                      David J Brewster and Bruce P Waxman
                      Med J Aust 2018; 209 (11): . || doi: 10.5694/mja18.00755
                      Published online: 10 December 2018

                      Much has been written recently about the mental health of the Australian medical workforce, with doctors being burned out, bullied, harassed and mentally unwell.1,2 Why are doctors so unkind to each other? What has happened to collegiality? While we are from different medical backgrounds, we are united in the belief that it is time for change; time for a united response from the Australian medical profession focusing on collegiality, using kindness and understanding as the catalyst and clinical handover as the opportunity.


                      • 1 Cabrini Clinical School, Monash University, Melbourne, VIC
                      • 2 Cabrini Health, Melbourne, VIC
                      • 3 School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC


                      Correspondence: dbrewster@cabrini.com.au
                      Acknowledgements: 

                      We thank Dr Malcolm Clark for his contribution to an earlier draft of this article.

                      Competing interests:

                      No relevant disclosures.

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