Led by Monash University and published in the Medical Journal of Australia, the recommendations address the unique challenges faced by some 39,000 people living with this chronic neurological condition.

Senior author Associate Professor Mastura Monif, a neurologist and researcher from the Monash University School of Translational Medicine and head of Alfred Health’s Neuroimmunology Service, said although Australia’s Therapeutic Goods Administration (TGA) adopted an international MS guideline in 2009 (which was last updated in 2015), specific and recent consensus recommendations were needed to guide best practice on locally available therapies and local practices.

“New disease-modifying therapies are more effective and better tolerated,” says Associate Professor Monif.

“But it’s a much more complex treatment landscape than it was 20 years ago, and there is new evidence being generated all the time on many aspects of the disease.

“It is really important that the approach used is focused on both the effectiveness and safety for the individual so they can get the best possible outcome.”

Developed by more than 30 experts from the Australian and New Zealand Association of Neurologists working group — including MS specialists, nurses, allied health professionals, and patient advocacy groups — the statement covers pre-assessment, therapy selection, monitoring, symptom management, and special considerations such as pregnancy and infections.

MS Australia CEO Rohan Greenland welcomes the guidelines as an “invaluable resource, especially for generalist clinicians navigating this rapidly evolving field”.

“They provide a clear and ready reference to best-practice evidence and expert consensus – an important milestone in MS care in Australia,” he says.

First author Dr Jessica Shipley, an MS and Neuroimmunology fellow at Alfred Health, says the recommendations are for everyone involved in managing MS, regardless of healthcare setting or location.

“These recommendations will be a valuable resource for everyone from GPs,  to neurologists, doctors in training, medical students, allied health professionals, nursing staff, and consumers or patients,” says Dr Shipley.

The recommendations can be found here:

• Part 1: Consensus recommendations on MS management in Australia and New Zealand.
• Part 2: Consensus recommendations ons MS management in Australia and New Zealand.

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A new paper published in Medical Journal of Australia found that although the incidence of type 2 diabetes continued to decline among Australian adults during 2010-2019 across all age, sex, socio-economic disadvantage and remoteness groups, incidence increased among people from particular ethnic backgrounds.

Head of Baker Heart and Diabetes Institute Diabetes and Population Health Lab, and first author of the paper, Professor Dianna Magliano, said that given these significant variances among cohorts, type 2 diabetes prevention strategies should have a strong focus on the differences in diabetes risk among populations.

“It’s a positive step that we are reducing the overall incidence of type 2 diabetes in Australia,” she said. “But in 2023, more than 30% of the Australian population was born overseas. We therefore need multifaceted approaches for preventing type 2 diabetes that take into account differences in the risk of developing diabetes, particularly among people with culturally and linguistically diverse backgrounds.”

The decline in overall incidence in Australia is similar to that reported for a number of other high-income countries, Prof Magliano said, and the increase in incidence among Australians born in Asia, North Africa, the Middle East and Pacific Islands is also consistent with substantial increases in type 2 diabetes prevalence in the Pacific Islands, the Middle East, and South Asia themselves.

“Several factors could explain this decline in Australia,” she said. “Firstly, some of the diabetes prevention strategies that we have implemented in Australia may have led to behavioural and environmental changes sufficient to influence the incidence of diagnosed diabetes. One good example of this is that the consumption of sugar-sweetened beverages in Australia is reported to have declined.

“And secondly, the shift from oral glucose tolerance testing to HbA1c assessment for diabetes screening may be a contributing factor to this decline in overall incidence.”

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Led by experts at the University of Adelaide, UNSW Sydney and Monash University, the evidence-based Australian Guidelines have been published in the Medical Journal of Australia alongside the launch of consumer resources including a new Monash Ask Fertility App.

The Guideline has been developed in engagement with consumers, including Indigenous and women from culturally and linguistically diverse (CALD) backgrounds.

CRE WHiRL is led by Monash University’s Professor Helena Teede, who joined University of Adelaide Professor Robert Norman and UNSW Sydney’s Dr Michael Costello as the experts leading the Guideline.

Professor Teede said the Guideline was developed using the most robust processes, involved all stakeholders including those with lived experience of infertility, and was approved by the NHMRC, so the community could be reassured it was trustworthy.

“Unexplained infertility greatly impacts quality of life, and it is important to ensure those affected receive the best advice and care for optimal outcomes, whilst avoiding rapidly rising use of often unproven treatments, increasing costs and inequity seen in Australia for those with unexplained infertility,” Professor Teede said.

“This new guideline will help to streamline and simplify treatments, potentially reducing cost and increasing equity, by avoiding complex testing and treatments that were not necessarily evidence-based. The Guideline’s evidence-based advice will play an important role in improving health outcomes for those with unexplained infertility and is adapted for the Australian health system and context,” Professor Norman added.

Dr Costello said that a lack of evidence-based guidelines and limited independent consumer information and empowerment strategies have compounded this. “The ESHRE and Australian Guideline uses the best available scientific evidence to guide health professionals in diagnosing and treating those with unexplained infertility,” he said.

The Guideline outlines the definition of unexplained infertility, diagnostic tests, treatments and differences between explained and unexplained infertility.

It is aimed at but not limited to general practitioners, gynaecologists, andrologists, infertility specialists, reproductive surgeons and those with unexplained infertility.

“The Guideline aims to assist healthcare professionals and couples in appropriate and effective management of the condition, acknowledging that each medical decision must consider individual characteristics, preferences, socioeconomic status, beliefs and values,” Dr Costello said.

“It should also be acknowledged that couples with unexplained infertility may experience considerable impact on their quality of life and they can be offered support and therapeutic counselling.”

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The warning bell has been sounded on the state of the health care system and its ability to adequately treat and triage youth mental health conditions.

Former Australian of the Year and prominent psychiatrist Professor Patrick McGorry has called for a reimagining of health care to address the “rising tide” of mental ill health in young Australians.

In a perspective published in The Medical Journal of Australia, Professor McGorry, Professor David Coghill and Professor Michael Berk argue that the mental health of many young Australians is rapidly declining and that young people with more complex conditions need access to intensive secondary care.

“A comprehensive youth mental health system involves much more than entry-level primary care,” they write.

“Young people with more severe, complex or persistent conditions need more expert, sustained and intensive care. Yet this next level of secondary care is largely absent, resulting in a large cohort of young people described as the ‘missing middle’.”

The recent National Study of Mental Health and Wellbeing revealed that the prevalence of mental disorders in 16–24-year-olds has risen by 50% — from 26% in 2007 to 39% in 2021.

The rise in young women is significantly greater than in young men, with rates reaching 48%.

The authors write that early intervention for potentially disabling illnesses safeguards mental wealth, notably with psychosis.

In the Perspective, the authors argue for four solutions.

1. Prevention and greater global understanding 

The first solution proposed is prevention and an increasing understanding of the trends occurring in a global society.

“The answers are likely to involve a blend of socio-economic and generational changes, rising adversity and inequality, and unforeseen consequences of technological advances,” they write.

2. Early intervention 

The second solution proposed is early intervention, involving integrated primary youth mental health care being the focal point.

“Primary care generally needs reimagining and a new financial model. The surge in need, workforce shortages and the collapse of bulk-billing has created a perfect storm both for GPs and headspace centres,” they write.

3. Multidisciplinary approach 

The third solution states that young people with more severe illnesses need expert, multidisciplinary teams to recover.

“This requires a more specialised tier of care, a back-up system for primary care providers for young people, so far only available in a small number of ‘oasis’ zones,” they write.

4. Changing funding distribution

The fourth solution involves changing how funding is distributed through the National Disability Insurance Scheme (NDIS).

“Young people in the early stages of potentially disabling mental illnesses, including treatable neurodevelopmental disorders such as [attention deficit/hyperactivity disorder (ADHD)], should be prioritised and no longer excluded,” they said.

Text: Medical Journal of Australia. 

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Using data from the West Australian longitudinal Raine Study Generation 2 cohort, which included 554 workers aged 22 years, the study found that total workplace productivity loss was up to 40% greater among 22-year-olds with clinical sleep disorders compared to their peers with no sleep disorders.

“This is equivalent to total workplace productivity loss (followed up on multiple occasions across 12 months) of about four weeks for young people with clinically significant sleep disorders, compared with less than one week for those without,” says Flinders University Associate Professor in Clinical Sleep Health Amy Reynolds, who led the study published by the Medical Journal of Australia.

“The Raine study previously showed that about 20% of the young adults surveyed had a common clinical sleep disorder, so this work eventuated because we wanted to know how much of an impact these disorders have on workers in their workplaces.

“The take-home message is just how prevalent sleep disorders are in young adults, and that these disorders are having an impact on our young adults and their workplaces.

“By middle age, it’s obstructive sleep apnoea that’s more prevalent, so it does change across the lifespan.

“But in young workers, it is insomnia which is more common, rather than other sleep problems, and is driving productivity loss.”

Associate Professor Reynolds, a provisional psychologist with the Insomnia Treatment Program at Flinders, says the productivity loss is largely driven by ‘presenteeism’.

“So, they’re at work, but they’re just not working to their best capacity or potential.”

Supporting the management of sleep disorders is a priority for researchers at the Flinders Health and Medical Research Institute Sleep Research group,  formerly the Adelaide Institute for Sleep Health

Senior co-author Professor Robert Adams and colleagues are focusing on giving GPs in primary care the ability to access appropriate, evidence-based care and resources for sleep disorders across all sectors of the population.

Supporting young people to access CBTi (cognitive behavioural therapy for insomnia), for example, can reduce the need for prescribing sleeping tablets or other interventions which may not tackle long-term sleep problems.

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The University of Sydney-led guidelines recommend that clinicians develop personalised deprescribing plans from the beginning for any patient being prescribed opioids.

The guidelines also advise clinicians against abruptly stopping opioid treatment without gradually reducing the dose or transitioning to different treatments, saying it could increase the risk of withdrawal symptoms.

This includes people with severe opioid use disorder, as doing so without giving them access to opioid substitution therapies can lead to a higher risk of overdose-related harm.

Recommendations also advise clinicians not to deprescribe opioids for people nearing end-of-life unless there are side effects.

The recommendations and summary of the guidelines are published in the Medical Journal of Australia.

The guidelines were led by 17 experts, which include general practitioners, pain specialists, addiction specialists, pharmacists, registered nurses, consumers, and physiotherapists.

The Evidence-based Guidelines for Deprescribing Opioid Analgesics is the first international guideline focussed on helping general practitioners to safely reduce opioid use for adults with pain and aims to improve the quality of care for patients.

Opioids are commonly prescribed to manage pain, with over 1.9 million adults starting opioid therapies each year in Australia. Approximately five per cent of patients who fill an opioid prescription transition to long-term use.

Senior author Associate Professor Danijela Gnjidic from the School of Pharmacy says opioid deprescribing may not be appropriate for every single person with emerging evidence that abruptly deprescribing opioids in patients, without support or pain management plans is associated with overdose-related harms and death.

“It is possible to reduce opioid use and harms without worsening pain, whilst maintaining or even improving quality of life. However, pain management should not be one-dimensional,” says Associate Professor Gnjidic.

“Before the release of the guidelines, in Australia, clinical guidelines have focused on pain management and prescribing of opioids. We needed evidenced-based guidelines focused on safely reducing or stopping prescribed opioids, and individualised care for patients.”

Pain management should not be ‘one size fits all’

“Opioids can be effective in pain management. However, over the longer term, the risk of harms may outweigh the benefits,” says fellow senior author Associate Professor Carl Schneider from the School of Pharmacy.

“Reducing the dose or discontinuing (deprescribing) opioids can be challenging, with additional complexity for Aboriginal and Torres Strait Islander Peoples and culturally and linguistically diverse communities. We received strong feedback on the need for specific resources for those communities on how to seek advice from healthcare professionals and be actively involved in decisions.”

Lead author Dr Aili Langford says the best available evidence that was interpreted and informed by expert opinion, and refined following extensive public consultation with healthcare professionals, organisations, policymakers and people who take opioids for pain.

“Internationally we were seeing significant harms from opioids, but also significant harms from unsolicited and abrupt opioid cessation. It was clear that recommendations to support safe and person-centred opioid deprescribing were required,” says Dr Langford, who worked on the report during her doctorate at the University of Sydney and is now based at Monash University.

Pain management a national and international priority

Pain and pain-related conditions are a leading cause of disability and disease burden globally. In Australia, one in five adults report having chronic pain.

Escalating opioid use and subsequent harm has been recognised as an international public health concern.

The World Health Organization has set a global goal of reducing severe avoidable medication-related harms. In 2020, Australia responded by identifying opioids as one of the four medicines of focus in the country.

The guidelines complement the national Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard, released last year by the Australian Commission on Safety and Quality in Health Care, which aims to stop inappropriate prescribing of opioids to treat acute pain in hospitals.

“It is incredibly important that we prescribe opioids safely and appropriately so that we don’t compromise the future health of Australians,” says Associate Professor Liz Marles, Clinical Director at the Commission and a general practitioner.

“These new guidelines further support the appropriate use of opioid analgesics and how to safely prescribe and stop prescribing them. They ask clinicians to consider reducing or stopping opioids when the risk of harm outweighs the benefits for the individual.

“Shared decision-making and ensuring that patients have ways to manage their pain are essential when a deprescribing plan is being discussed. Ultimately, we are all working to reduce the number of Australians at risk of harm from long-term opioid use, which will have broad societal benefits,” says Associate Professor Marles.

For more information, visit: australiandeprescribingnetwork.com.au.

Text by: The University of Sydney. 

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The authors of an article recently published in the Medical Journal of Australia’s Perspectives series support this notion, revealing that when it comes to medication management of older people, clear communication is even more important.

With older people often having complicated medication schedules, the researchers say communication breakdowns between the healthcare services they require may put them at risk of medication-related problems and hospitalisation.

Medication miscommunication, they add, may lead to patients not being fully informed about their medications or having the opportunity to ask required questions.

They say conversations about medications are needed more frequently, with more family involvement, while communication around medication also needs to be better tailored to what the individual patient needs to understand and remember.

Lead author Professor Elizabeth Manias, from the Centre for Quality and Patient Safety Research at Deakin University, and her colleagues say older patients are likely to have complex medication regimens that need to be carefully managed as they move across and within diverse settings, “including primary care, acute care, geriatric rehabilitation, and aged care facilities” and involving different health professionals across specialties.

“Discussions with older patients and families are often not prioritised across transitions of care. Instead, fleeting conversations take place at irregular time points and for short periods just before or after transfers,” Professor Manias and colleagues wrote.

“These conversations are rarely organised in a goal-directed way where medication communication is conveyed accurately, clearly, and comprehensively.

“The impact of fleeting conversations is that even if medication information is conveyed, patients and families may not be involved in key decisions about newly prescribed, ceased or changed medications, or may not voice their concerns and preferences about the medication regimen.

“There is a lack of recognition that ‘the one person who remains constant is the patient, who has the most to lose in a disconnected health system’.”

How to ensure clear communication 

Professor Manias and colleagues recommend the following principles:

• Communication about medication should occur throughout the duration of older patients’ care, rather than being limited to particular time points.
• Families should be included in medication communication at every opportunity, rather than waiting until medication counselling occurs just before hospital discharge or just before completing a primary care consultation.
• Communication needs to be tailored to each patient’s ability to comprehend, with clear, easy-to-understand language, using resources including diagrams, photographs of medications, audio and video recorded materials, simulations and patient case scenarios.
• Doctors, nurses, pharmacists and other health professionals need to acknowledge they all have important roles in communicating with each other about medication across transitions of care.
• Health professionals need to regularly seek outpatient and family priorities and preferences, especially if medication changes are made. Older patients and families should be encouraged to ask questions.
• Shared decision-making should be supported by communicating with patients and their families about the current medications they take, the consequences that may occur if medications are not consumed, the time when these are reviewed to decide if they will be continued, and the person who conducts the review.
• In facilitating informed consent to prescribing medications, decision aids can be helpful. Their use should be documented in medical records for future retrieval.

“Fostering engagement among older patients and families and creating opportunities for decision making about medications are crucial for improved safety and quality across transitions of care,” Professor Manias and colleagues wrote.

“Challenging fleeting conversations is key to reducing the risk of medication-related problems and patient harm.”

For more information, visit: doi.org/10.5694/mja2.51651

This feature was originally published in the September issue of Retail Pharmacy magazine. 

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Below a team of Australian researchers outline several strategies we can use to help the healthcare system respond better when climate disaster strikes to make sure nobody is left behind.

Health practitioners have the opportunity to contribute their expertise to help reduce the health consequences of climate disasters across the prevention, preparedness, response and recovery phases of disaster management, say the authors of a Perspective published today by the Medical Journal of Australia.

Apart from the acute health consequences of extreme weather events – deaths from drowning, injuries, poisonings and infections – climate disasters interrupt treatment and overall health care, exacerbating conditions or even causing deaths, wrote the authors, led by Professor Sotiris Vardoulakis, Professor of Global Environmental Health at the National Centre for Epidemiology and Population Health, Australian National University.

“Underlying vulnerabilities, including obesity, diabetes, cancer, mental illness and other non-communicable diseases (NCDs), complicate disaster recovery efforts in communities affected by extreme events,” they wrote.

“Interruption may be caused by loss of belongings including medication, damaged transport routes, reduced health services, disrupted telecommunications, loss of power, and evacuations, often compounded by disrupted sleep, stress and reduced access to healthy food and safe water.”

Professor Vardoulakis and colleagues point out that health professionals have responded heroically to Covid-19, bushfires and floods over the past 2 years “but it is not sustainable in the long run”.

“Extreme events, pandemic fatigue, overstretched clinical services, spiralling demand for mental health services, and staff burnout could drive the health care workforce to collapse,” they wrote.

“Beyond the health system, the Covid-19 pandemic has altered the social capital (i.e., community attachment, solidarity and social trust) and exposed health inequities in our communities.

“Disaster preparedness and recovery plans should be developed in partnership with disability organisations and community grassroots, including Aboriginal and Torres Strait Islander communities, to ensure that scientific knowledge is combined with local knowledge gained from experience and built from the ground up.”

Professor Vardoulakis and colleagues call for:

• “[The development of] a coordinated cross-sectoral whole-of-system response (health, environment, land-use planning, social housing) to floods, strongly focusing on long-term public health prevention and preparedness for more frequent and intense extreme events. This should incorporate meaningful community engagement, including Aboriginal and Torres Strait Islander, culturally and linguistically diverse, and socio-economically marginalised communities, to build social cohesion, reduce inequities and develop culturally appropriate risk communication strategies and person-centred adaptation plans.
• “[The strengthening of] non-communicable disease (NCD) prevention, including mental health and wellbeing services, particularly for rural and remote communities disproportionally affected by environmental change and extreme events.
• “[The implementation of] a stronger environmental public health surveillance for infectious diseases and NCDs, and climate-informed predictive models and early warning systems linked to emergency, public and mental health services.
• “[The establishment of] a sustainable health unit (similar to Greener National Health Service in England) that will help improve the health sector’s resilience to climate and health emergencies, and monitor and reduce the carbon footprint of health services.
• “[An increase in] research capacity and capability and identifying gaps in local service delivery, communication and coordination, with a strong focus on the evaluation of interventions aiming to increase health sector and community resilience, particularly of at-risk populations, to floods and other climate disasters.”

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Living guidelines can be updated as new evidence becomes available so that they remain current and up to date with the latest data.

The Australian and New Zealand living guidelines for stroke management are said to be the first of their kind globally.

More than 30 new and updated recommendations have been made since 2018, including five new strong recommendations. Three updates graded as strong recommendations have also been made.

Details of the updates can be found here: informme.org.au/guidelines/clinical-guidelines-for-stroke-management 

“Rapid guideline updates as part of a living model are almost certain to have played a significant role by expediting local and state-wide system changes,” wrote the authors of the summary, led by Professor Coralie English, from the University of Newcastle.

“Importantly, living guidelines provide currency of advice. The experience with stroke as well as other guidelines demonstrates that the rigour of the methods does not need to be compromised when living modes are adopted.

“Our model of continual evidence surveillance and timely updates to recommendations is feasible, but sustainability remains a challenge.

“Now that we have started down this road, the message from guideline end-users is that a return to the old model of static updates is no longer acceptable, and ongoing long term investment in living guidelines must be prioritised,” Professor English and colleagues said.

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Professor Benjamin Howden, Director of the Public Health Laboratory at the University of Melbourne, and colleagues, report on a case of reinfection in one Melbourne household.

“In late July 2021, three people in one Melbourne household were diagnosed with Covid-19 … All three patients had also been diagnosed with Covid-19 in July 2020, during a period of high community transmission in Victoria,” write Professor Howden and colleagues.

“[Genome] sequences were available for the 2021 infections from all three patients, and for the 2020 infections from two of the patients. The 2021 sequences were genetically distinct from the 2020 sequences.

“Instead, they were closely related to sequences associated with the workplace of two of the patients, which was the site of a recent Covid outbreak, and to other recent sequences from Victoria and New South Wales.

“The phylogenetic data, together with the link with a known Covid-19 outbreak, indicate that the 2021 Covid-19 diagnoses reflected new infections rather than prolonged viral shedding [from the first infection].

“The three patients had no known immunocompromising conditions and were not eligible for Covid-19 vaccination at the time of either of their infections.

“Illness severity was similar during the first and second infections – with neither respiratory support nor hospitalisation required.”

Professor Howden and colleagues write that people who have recovered from Covid-19 may be “less likely to seek vaccination”.

According to Australian government recommendations, there is no requirement to delay Covid-19 vaccination once a patient has recovered from acute illness.

Patients should speak to their medical provider regarding optimal timing for vaccination.

“The occurrence of second infections in Australia, where the incidence of Covid-19 has been relatively low, indicates that doctors should encourage recovered patients to be vaccinated and that public awareness of the possibility of reinfection should be promoted to encourage vaccination, testing, and protective behaviours.”

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