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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
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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.
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.
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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No relevant disclosures.
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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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.
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.
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.
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We thank Dr Malcolm Clark for his contribution to an earlier draft of this article.
No relevant disclosures.
Celebrating a great year for the MJA with our 2018 holiday issue
Welcome to the traditional summer edition of the MJA! In place of all the ground-breaking research, expert reviews, meta-analyses, and penetrating perspectives we publish throughout the year, we present a fascinating potpourri of the amusing and interesting articles and commentaries we have received as entries for our annual Christmas competition, before reviewing the best research we published during 2018.
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No relevant disclosures for this article. A complete list of my conflict of interest disclosures is found at
Introduction: The evidence‐based national clinical practice guidelines for the management of cutaneous melanoma published in 2008 are currently being updated. This article summarises the findings from multiple chapters of the guidelines on different methods of melanoma detection and of monitoring the skin for patients at high risk of melanoma. Early detection of melanoma is critical, as thinner tumours are associated with enhanced survival; therefore, strategies to improve early detection are important to reduce melanoma‐related mortality.
Main recommendations:
Management overview: Determining the relative indications for each diagnostic method and how each method should be introduced into the surveillance of a patient requires careful consideration and an individualised approach.
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The development of the new Australian clinical practice guidelines for the diagnosis and management of melanoma was funded by Cancer Council Australia and the Melanoma Institute Australia, with additional support from the Skin Cancer College Australasia and the Australasian College of Dermatologists. Nikki Adler is supported by a Research Training Program stipend scholarship, Monash University. H Peter Soyer has an NHMRC Practitioner Fellowship. John Thompson is supported by the Melanoma Foundation at the University of Sydney.
No relevant disclosures.
The fascinating history of the multichannel cochlear implant and its inventor, Professor Graeme Clark
A cochlear implant is a surgically implanted device for converting sounds into an electrical current that directly stimulates the cochlear nerve.1 It consists of external (microphone, speech processor, transmitter) and internal components (receiver/stimulator, electrode array in the cochlea) and can be implanted in both children and adults.
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All images provided courtesy of Cochlear Limited.
No relevant disclosures.
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We thank Dr Elizabeth Ebert (Australian Bureau of Meteorology) for contributing indicator 2.4 (Climate information services for health). We also thank Dr Luke Knibbs (University of Queensland) who provided assistance with the PM monitor data for indicator 3.5.1 (Exposure to air pollution in cities). Indicator 3.9 (Health care sector emissions) builds on Malik et al ( 2018; 2: e27–e35) and we would like to acknowledge the co-authors of that publication: Prof Manfred Lenzen, Dr Forbes McGain and Scott McAlister. We would also like to acknowledge Fabiola Barba Ponce (Macquarie University).
Anthony Capon directs the human health and social impacts research node of the NSW Adaptation Research Hub.
We need to move beyond managing end organ complications to reducing cardio-renal risk across the spectrum of kidney function
Type 2 diabetes mellitus is one of the greatest challenges facing the Australian health care system. The number of Australians living with diabetes has tripled over the past 25 years, and by 2025 it is expected that 3 million adults will have been diagnosed with the disease, one of the most rapid rises for any chronic condition in Australia.1
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Brendon Neuen is funded by a John Chalmers PhD Scholarship from the George Institute for Global Health and a University Postgraduate Award from UNSW Sydney. Vlado Perkovic receives research support from the National Health and Medical Research Council (Senior Research Fellowship and Program Grant).
The George Institute for Global Health provides contract research services to Janssen for trials of sodium/glucose cotransporter 2 (SGLT2) inhibitors. Brendon Neuen receives travel support from Janssen. Vlado Perkovic is the chair of a steering committee for a renal outcome study of an SGLT2 inhibitor (canagliflozin), serves on steering committees for AbbVie, Boehringer Ingelheim, GlaxoSmithKline, Janssen and Pfizer, and serves on advisory boards or speaks at scientific meetings for AbbVie, Astellas, AstraZeneca, Bayer, Baxter, Bristol-Myers Squibb, Boehringer Ingelheim, Durect, Eli Lilly, Gilead, GlaxoSmithKline, Janssen, Merck, Novartis, Novo Nordisk, Pfizer, Pharmalink, Relypsa, Roche, Sanofi, Servier and Vitae; all honoraria for these activities are paid to the George Institute for Global Health.
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.