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    The impact of non-vitamin K antagonist oral anticoagulants (NOACs) on anticoagulation therapy in rural Australia

    Jamie W Bellinge, Jarrad J Paul, Liam S Walsh, Lokesh Garg, Gerald F Watts and Carl Schultz
    Med J Aust 2018; 208 (1): . || doi: 10.5694/mja17.00132
    Published online: 15 January 2018

    Abstract

    Objective: To determine the use of different anticoagulation therapies in rural Western Australia; to establish whether remoteness from health care services affects the choice of anticoagulation therapy; to gather preliminary data on anticoagulation therapy safety and efficacy.

    Design: Retrospective cohort study of patients hospitalised with a principal diagnosis of atrial fibrillation/flutter (AF) or venous thromboembolism (VTE) during 2014–2015.

    Setting: Four hospitals serving two-thirds of the rural population of Western Australia.

    Participants: 609 patients with an indication for anticoagulation therapy recorded in their hospital discharge summary for index admission.

    Main outcome measures: Prescribing rates of anticoagulation therapies by indication for anticoagulation and distance of patient residence from their hospital. The primary safety outcome was re-hospitalisation with a major or clinically relevant non-major bleeding event; the primary lack-of-efficacy outcome was re-hospitalisation for a thromboembolic event.

    Results: The overall rates of prescription of NOACs and warfarin were similar (34% v 33%). A NOAC was prescribed more often than warfarin for patients with AF (56.0% v 42.2% of those who received an anticoagulant; P < 0.001), but less often for patients with VTE (29% v 48%; P < 0.001). Warfarin was prescribed for 38% of patients who lived locally, a NOAC for 31% (P = 0.013); for non-local patients, the respective proportions were 29% and 36% (P = 0.08). 69% of patients with AF and a CHA2DS2–VASc score ≥ 1 were prescribed anticoagulation therapy. Patients treated with NOACs had fewer bleeding events than patients treated with warfarin (nine events [4%] v 20 events [10%]; P = 0.027).

    Conclusions: In rural WA, about one-third of patients with an indication for anticoagulation therapy receive NOACs, but one-third of patients with AF and at risk of stroke received no anticoagulant therapy, and may benefit from NOAC therapy.

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    • 1 Royal Perth Hospital, Perth, WA
    • 2 Bunbury Regional Hospital, Bunbury, WA
    • 3 South West Health Campus, Bunbury, WA
    • 4 University of Western Australia, Perth, WA


    Competing interests:

    No relevant disclosures.

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      Investing in men’s health in Australia

      James A Smith, Mick Adams and Jason Bonson
      Med J Aust 2018; 208 (1): . || doi: 10.5694/mja17.00173
      Published online: 15 January 2018

      Building leadership, governance and evaluation capacity to improve men’s health outcomes

      Research has consistently shown a sex differential in illness and mortality between men and women.1 It is widely acknowledged that this difference relates to a combination of biological and sociological factors, including the social construction of gender.1,2 Empirical evidence shows that life expectancy among men in Australia has raised slightly over the past decade.1 However, the report by the Australian Institute of Health and Welfare The health of Australia’s males1 indicates that some men make healthy lifestyle choices and have positive health outcomes. About two-thirds of men participate in sports or physical activities, nearly 40% discuss health lifestyle concerns with a health professional, 20% rate their health as excellent, and survival rates for prostate cancer and testicular cancer in Australia are improving.1 Yet, popular wisdom would have us believe that men are stoic and do not seek help or use health services.2 There are clear indications that the tides are changing.


      • 1 Charles Darwin University, Darwin, NT
      • 2 Australian Indigenous HealthInfoNet, Edith Cowan University, Perth, WA
      • 3 Men's Health Strategy Unit, Department of Health, Darwin, NT


      Correspondence: james.smith3@cdu.edu.au
      Acknowledgements: 

      We thank the NT Government Department of Local Government and Community Services (now Department of Housing and Community Development) for the provision of a Men’s Leadership Grant to undertake the NT Indigenous Male Research Strategy Think Tank.

      Competing interests:

      No relevant disclosures.

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      • 21. Adams M. Aboriginal Life Set, mental health and suicide. In: Fejo-King C, Poona J, editors. Reconciliation and Australian social work — past and current experiences informing future practice. Canberra: Magpie Goose Publishing, 2015; pp 33-74.
      • 22. Ashfield J, Macdonald J, Smith A. A “situational approach” to suicide prevention: why we need a paradigm shift for effective suicide prevention. Australian Institute of Male Health and Studies and Western Sydney University; 2017. http://aimhs.com.au/cms/uploads/Situational%20Approach%20Document_web.pdf (accessed Oct 2017).
      • 23. Connell RW, Department of Health and Aged Care. Men’s health: a research agenda and background report. Canberra: Commonwealth of Australia; 1999.
      • 24. National Health and Medical Research Council. The NHMRC Road Map II: a strategic framework for improving the health of Aboriginal and Torres Strait Islander people through research. Canberra: Commonwealth of Australia; 2010. https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/r47.pdf (accessed Nov 2017).

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        Towards a theoretically informed policy against a rakghoul plague outbreak

        Dimitrios-Georgios Kontopoulos, Theano Kontopoulou, Hsi-Cheng Ho and Bernardo García-Carreras
        Med J Aust 2017; 207 (11): . || doi: 10.5694/mja17.00792
        Published online: 11 December 2017

        Summary

        A long time ago in a galaxy far, far away, the Sith Lord Karness Muur engineered the rakghoul plague, a disease that transformed infected humans into near-mindless predatory rakghouls. At its peak, the disease infected millions of individuals, giving rise to armies of rakghouls on a number of planets. Whether rakghoul populations have persisted until this day is not known, making a rakghoul invasion on Earth not completely improbable. Further, a strategy for defence against an outbreak of the disease on Earth has not yet been proposed. To fill this glaring gap, we developed the first mathematical model of the population dynamics of humans and rakghouls during a rakghoul plague outbreak. Using New South Wales as a model site, we then obtained ensembles of model predictions for the outcome of the rakghoul plague in two different disease control strategy scenarios (population evacuation and military intervention), and in the absence thereof. Finally, based on these predictions, we propose a set of policy guidelines for successfully controlling and eliminating outbreaks of the rakghoul plague in Australian states.

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        • 1 Imperial College London, Silwood Park Campus, Ascot, Berkshire, United Kingdom
        • 2 Evangelismos Hospital, Athens, Greece


        Acknowledgements: 

        We thank Samraat Pawar for providing comments on an early draft of our article.

        Competing interests:

        No relevant disclosures.

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          The Specialty and Naughty/Nice Tendency Audit (SANTA): which medical specialists can be trusted to follow recipes?

          Shian Miller and Tamara C Johnson
          Med J Aust 2017; 207 (11): . || doi: 10.5694/mja17.00811
          Published online: 11 December 2017

          Abstract

          Objective: To evaluate the influence of medical specialty on the likelihood of doctors making the Naughty or Nice lists this Christmas.

          Design, setting, and participants: A quantitative observational study. Doctors in a medical parent Facebook group were asked about their specialty and their tendency to follow recipes.

          Main outcome measures: Self-reported tendency to follow the recipe (always, sometimes, never) as an indicator of rule-breaking behaviour, extrapolated as indicating Naughty (unlikely to follow a recipe) or Nice (always follow recipes) tendencies, and consequently the likelihood of being included in the Nice list this Christmas.

          Results: The majority of doctors in only 19% of specialties made the Nice list. When aggregated, 92% of surgical specialties reported that they either never followed recipes or did so only occasionally. Similarly, 80% of physician specialties reported being Naughty. In contrast, 50% each of those in critical care specialties were Naughty or Nice. General practitioners comprised the largest single group of respondents, and only 8% identified as Nice.

          Conclusions: An overwhelming majority of medical parents were Naughty. As Santa makes his list and checks it twice, he will find out who is Naughty or Nice, and he may be surprised at the number of doctors who are on the wrong side of the inventory. When Santa Claus comes to town, he should be circumspect when indulging in any baked offerings by the Christmas tree, particularly those offered by surgeons and general practitioners.

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          • 1 Greenslopes Private Hospital, Brisbane, QLD
          • 2 Western Sydney University School of Medicine, Sydney, NSW


          Correspondence: shianmiller@gmail.com
          Competing interests:

          No relevant disclosures.

          • 1. Hojat M, Zuckerman M. Personality and specialty interest in medical students. Med Teach 2008; 30: 400-406.
          • 2. Patterson D. Do recipes make you a better cook? [webpage]. Food & Wine, 30 June 2006. http://www.foodandwine.com/articles/do-recipes-make-you-a-better-cook (accessed Sept 2017).
          • 3. Kotsis V, Chung KC. Application of See One, Do One, Teach One concept in surgical training. Plast Reconstr Surg 2013; 131: 1194-1201.

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            Tooth Fairy guilty of favouritism!

            Raphael Patcas, Hubertus JM van Waes, Moritz M Daum and Markus A Landolt
            Med J Aust 2017; 207 (11): . || doi: 10.5694/mja17.00860
            Published online: 11 December 2017

            Abstract

            Objectives: To determine the proportion of children visited by the Tooth Fairy, the child-related factors that influence the likelihood of her visit, and the parent-related variables that affect the amount of money the Tooth Fairy leaves.

            Design: Cross-sectional questionnaire study.

            Setting: Zürich, Switzerland.

            Participants: 3617 parents of children (mean age of children, 6.8 years; 51.9% girls) who had lost at least one deciduous tooth received a self-developed questionnaire; 1274 questionnaires were returned (35.2%).

            Main outcome measures: Primary outcome variables were the Tooth Fairy’s visit after tooth loss and the amount of money given in case of a visit. Child- and parent-related variables were assessed as predictors of the main outcomes.

            Results: Most parents (71.0%) reported that the Tooth Fairy visited their child. She usually exchanged the lost tooth for money (55.8% of visits) or placed money next to the tooth (40.7%); rarely did she take the tooth without pecuniary substitution. The Tooth Fairy left an average of 7.20 Swiss francs (approximately AU$9.45). The Tooth Fairy favoured visiting for the teeth of older children (odds ratio [OR], per year, 1.87; 95% CI, 1.09–3.21), of boys (OR, 2.65; 95% CI, 1.09–6.42), and of children who believed in her (OR, 4.12; 95% CI, 1.77–9.64). The amount of money was influenced by maternal, but not paternal socio-demographic factors, including level of education (OR, per level, 0.78; 95% CI, 0.66–0.92) and country of origin (OR, Western countries v non-Western countries, 2.35; 95% CI, 1.20–4.62).

            Conclusions: The Tooth Fairy does not visit all children after tooth loss, displaying clear preferences in her choice of business partners. The odds of a visit are dramatically increased if she is believed in, and the value of a deciduous tooth is influenced by socio-demographic factors.

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            • 1 Centre of Dental Medicine, University of Zurich, Zürich, Switzerland
            • 2 Stadt Zürich Schul- und Sportdepartement, Zürich, Switzerland
            • 3 University of Zurich, Zürich, Switzerland
            • 4 Neuroscience Centre, University of Zurich and ETH Zurich, Zürich, Switzerland
            • 5 University Children's Hospital Zurich, Zürich, Switzerland


            Correspondence: raphael.patcas@zzm.uzh.ch
            Competing interests:

            No relevant disclosures.

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              Neville Wran’s voice: how the Premier’s Teflon-coated vocal cords came unstuck

              Evangelos Tseros, Faruque Riffat, Carsten E Palme, Hedley G Coleman and Narinder P Singh
              Med J Aust 2017; 207 (11): . || doi: 10.5694/mja17.00198
              Published online: 11 December 2017

              His gravelly voice became one of the successful politician’s most defining features

              Neville Kenneth Wran was the colourful and charismatic Premier of New South Wales from 1976 to 1986. He was widely respected for his quick wit, engaging informality, and committed representation of blue collar voters. The youngest of eight siblings, he was born in 1926 and raised in the Sydney suburb of Balmain, then a working class stronghold of the Australian Labor Party1 (Box 1).


              • 1 Westmead Hospital, Sydney, NSW
              • 2 University of Sydney, Sydney, NSW
              • 3 Institute for Clinical Pathology and Medical Research, Westmead Hospital, Sydney, NSW


              Competing interests:

              No relevant disclosures.

              • 1. Steketee M, Cockburn M. Wran: an unauthorised biography. Sydney: Allen & Unwin, 1986.
              • 2. Mallur PS, Rosen CA. Vocal fold injection: review of indications, techniques, and materials for augmentation. Clin Exp Otorhinolaryngol 2010; 3: 177-182.
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              • 4. Meslemani D, Benninger MS. Coblation removal of laryngeal Teflon granulomas. Laryngoscope 2010; 120: 2018-2021.
              • 5. Li L, Stiadle JM, Lau HK, et al. Tissue engineering-based therapeutic strategies for vocal fold repair and regeneration. Biomaterials 2016; 108: 91-110.
              • 6. Friedrich G, Dikkers FG, Arens C, et al. Vocal fold scars: current concepts and future directions. Consensus report of the Phonosurgery Committee of the European Laryngological Society. Eur Arch Otolraryngol 2013; 270: 2491-2507.
              • 7. Dailey SH, Ng K, Gunderson M, Petty B. Vocal fold reconstruction: a novel flap. Laryngoscope 2013; 123: 2793-2797.
              • 8. Pagedar NA, Listinsky CM, Tucker HM. An unusual presentation of Teflon granuloma: case report and discussion. Ear Nose Throat J 2009; 88: 746-747.
              • 9. Loehrl TA, Smith TL. Inflammatory and granulomatous lesions of the larynx and pharynx. Am J Med 2001; 111 Suppl 8A: 113s-117s.
              • 10. Bramston T. Wran’s plan a way back for NSW Labor. The Australian (Sydney). 4 June 2011. http://www.theaustralian.com.au/national-affairs/wrans-plan-a-way-back-for-nsw-labor/news-story/d434e7b75b1dd86d2b8da564b4d1d015 (accessed Sept 2017).

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                Safeguarding the health of future generations

                Elizabeth O'Brien
                Med J Aust 2017; 207 (11): . || doi: 10.5694/mja17.p1112
                Published online: 11 December 2017

                The planet will continue to revolve in the face of declining ecosystem health and diversity, but how will the human species fare in 20, or 200, years? Is there a health framework to resist the free market call to relentless expansion, economic growth and profit? What is our role as doctors in advocating for the voiceless, future inhabitants of this planet?


                • Port Macquarie Base Hospital, Port Macquarie, NSW


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                  The MJA 2017: the year in review, and looking forward to 2018

                  Nicholas J Talley
                  Med J Aust 2017; 207 (11): . || doi: 10.5694/mja17.01025
                  Published online: 11 December 2017

                  In multicultural Australia, whatever your religious beliefs or cultural background, we celebrate together the summer holiday period and our shared values of family and community. On behalf of the entire MJA team, we welcome you to the 2017 Christmas issue of the Journal, a tradition in which we strive to amuse and entertain our readers over the holiday season.

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                  • Editor-in-Chief, Medical Journal of Australia


                  Competing interests:

                  No relevant disclosures.

                  • 1. Talley NJ. A prize, an award and Christmas crackers: season’s greetings from the MJA. Med J Aust 2016; 205: 494-495. <MJA full text>
                  • 2. McCullough AR, Pollack AJ, Hansen MP, et al. Antibiotics for acute respiratory infections in general practice: comparison of prescribing rates with guideline recommendations. Med J Aust 2017; 207: 65-69. <MJA full text>
                  • 3. Moayyedi P, Yuan Y, Baharith H, Ford AC. Faecal microbiota transplantation for Clostridium difficile-associated diarrhoea: a systematic review of randomised controlled trials. Med J Aust 2017; 207: 166-172. <MJA full text>
                  • 4. Archer BN, Chiu CK, Jayasinghe SH, et al. Epidemiology of invasive meningococcal B disease in Australia, 1999–2015: priority populations for vaccination. Med J Aust 2017; 207: 382-387. <MJA full text>
                  • 5. Tong EY, Roman CP, Mitra B, et al. Reducing medication errors in hospital discharge summaries: a randomised controlled trial. Med J Aust 2017; 206: 36-39. <MJA full text>
                  • 6. Chew DP, Scott IA, Cullen L, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. Med J Aust 2016; 205: 128-133. <MJA full text>
                  • 7. Parsonage WA, Milburn T, Ashover S, et al. Implementing change: evaluating the Accelerated Chest pain Risk Evaluation (ACRE) project. Med J Aust 2017; 207: 201-205. <MJA full text>
                  • 8. Cullen L, Greenslade JH, Hawkins T, et al. Improved Assessment of Chest pain Trial (IMPACT): assessing patients with possible acute coronary syndromes. Med J Aust 2017; 207: 195-200. <MJA full text>
                  • 9. Chambers GM, Paul RC, Harris K, et al. Assisted reproductive technology in Australia and New Zealand: cumulative live birth rates as measures of success. Med J Aust 2017; 207: 114-118. <MJA full text>
                  • 10. Ibrahim JE, Bugeja L, Willoughby M, et al. Premature deaths of nursing home residents: an epidemiological analysis. Med J Aust 2017; 206: 442-447. <MJA full text>
                  • 11. Rakhra SS, Opdam HI, Gladkis L, et al. Untapped potential in Australian hospitals for organ donation after circulatory death. Med J Aust 2017; 207: 294-301. <MJA full text>
                  • 12. Playford D, Ngo H, Gupta S, Puddey IB. Opting for rural practice: the influence of medical student origin, intention and immersion experience. Med J Aust 2017; 207: 154-158. <MJA full text>

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                    COPD-X Australian and New Zealand guidelines for the diagnosis and management of chronic obstructive pulmonary disease: 2017 update

                    Ian A Yang, Juliet L Brown, Johnson George, Sue Jenkins, Christine F McDonald, Vanessa M McDonald, Kirsten Phillips, Brian J Smith, Nicholas A Zwar and Eli Dabscheck
                    Med J Aust 2017; 207 (10): . || doi: 10.5694/mja17.00686
                    Published online: 20 November 2017

                    Abstract

                    Introduction: Chronic obstructive pulmonary disease (COPD) is characterised by persistent respiratory symptoms and chronic airflow limitation, and is associated with exacerbations and comorbidities. Advances in the management of COPD are updated quarterly in the national COPD guidelines, the COPD-X plan, published by Lung Foundation Australia in conjunction with the Thoracic Society of Australia and New Zealand and available at http://copdx.org.au.

                    Main recommendations:

                    • Spirometry detects persistent airflow limitation (post-bronchodilator FEV1/FVC < 0.7) and must be used to confirm the diagnosis.
                    • Non-pharmacological and pharmacological therapies should be considered as they optimise function (ie, improve symptoms and quality of life) and prevent deterioration (ie, prevent exacerbations and reduce decline).
                    • Pulmonary rehabilitation and regular exercise are highly beneficial and should be provided to all symptomatic COPD patients.
                    • Short- and long-acting inhaled bronchodilators and, in more severe disease, anti-inflammatory agents (inhaled corticosteroids) should be considered in a stepwise approach.
                    • Given the wide range of inhaler devices available, inhaler technique and adherence should be checked regularly.
                    • Smoking cessation is essential, and influenza and pneumococcal vaccinations reduce the risk of exacerbations.
                    • A plan of care should be developed with the multidisciplinary team. COPD action plans reduce hospitalisations and are recommended as part of COPD self-management.
                    • Exacerbations should be managed promptly with bronchodilators, corticosteroids and antibiotics as appropriate to prevent hospital admission and delay COPD progression.
                    • Comorbidities of COPD require identification and appropriate management.
                    • Supportive, palliative and end-of-life care are beneficial for patients with advanced disease.
                    • Education of patients, carers and clinicians, and a strong partnership between primary and tertiary care, facilitate evidence-based management of COPD.

                     

                    Changes in management as result of the guideline: Spirometry remains the gold standard for diagnosing airflow obstruction and COPD. Non-pharmacological and pharmacological treatment should be used in a stepwise fashion to control symptoms and reduce exacerbation risk.


                    • 1 University of Queensland, Brisbane, QLD
                    • 2 Prince Charles Hospital, Brisbane, QLD
                    • 3 COPD National Program, Lung Foundation Australia, Brisbane, QLD
                    • 4 Centre for Medicine Use and Safety, Monash University, Melbourne, VIC
                    • 5 Curtin University, Perth, WA
                    • 6 Sir Charles Gairdner Hospital, Perth, WA
                    • 7 Austin Hospital, Melbourne, VIC
                    • 8 University of Melbourne, Melbourne, VIC
                    • 9 Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, NSW
                    • 10 John Hunter Hospital, Newcastle, NSW
                    • 11 Queen Elizabeth Hospital, Adelaide, SA
                    • 12 University of New South Wales, Sydney, NSW
                    • 13 Alfred Health, Melbourne, VIC


                    Correspondence: ian.yang@health.qld.gov.au
                    Acknowledgements: 

                    We thank Lung Foundation Australia and the Thoracic Society of Australia and New Zealand for their support in the preparation of these guidelines.

                    Competing interests:

                    The conflict of interest declarations for Ian Yang, Johnson George, Sue Jenkins, Christine McDonald, Vanessa McDonald, Brian Smith, Nick Zwar and Eli Dabscheck are listed on the Lung Foundation Australia website ().

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                      Spirometry: key to the diagnosis of respiratory disorders

                      John R Wheatley
                      Med J Aust 2017; 207 (10): . || doi: 10.5694/mja17.00684
                      Published online: 20 November 2017

                      Spirometry remains the cornerstone of respiratory function testing and is the key to diagnosing and monitoring the most common respiratory disorders. Spirometry measures how quickly the air can empty from the lungs (flow) and how much air can be moved during a maximal expiration (volume). It is a valuable clinical tool to detect diseases that impair respiratory function, help exclude respiratory disease as a cause of current symptoms, assess the severity of any impairment in function, and monitor the effects of any therapeutic intervention or of disease progression.


                      • Westmead Hospital and University of Sydney, Sydney, NSW


                      Correspondence: john.wheatley@sydney.edu.au

                       

                      Series editors

                      Balakrishnan (Kichu) Nair

                      Simon O’Connor

                      Competing interests:

                      No relevant disclosures.

                      • 1. Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J 2005; 26: 319-338.
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