Internal Medicine Journal最新文献

Background: Post-colonoscopy colorectal cancer (PCCRC), defined as colorectal cancer (CRC) detected after a cancer-negative colonoscopy, represents a key quality indicator for CRC detection and prevention. While most PCCRC is attributed to missed lesions, few studies examine pathologic and molecular characteristics of PCCRC to assess for possible de novo cancer formation causing PCCRC.

Aim: The aim of this study was to identify cases of PCCRC where prior colonoscopy was adequate (A-PCCRC) versus inadequate (I-PCCRC) and compare both subtypes with spontaneous CRC (sCRC) in terms of patient factors, histopathology and molecular characteristics.

Methods: This was a 12-year retrospective population-based study using a data set from the Western Australian Cancer Registry between 2000 and 2011. A-PCCRCs were identified by excluding lesions likely missed due to procedural factors or incomplete prior resection at index colonoscopy performed within 3-36 months of cancer diagnosis. Histopathological review and next-generation sequencing were conducted on subsets of patients with A-PCCRC and sCRC. Statistical analysis included univariable and multivariable regression models and chi-squared and Wilcoxon rank sum tests.

Results: A total of 524 (3.81%) cases of PCCRC were identified out of 13 757 cases of CRC; 272 were A-PCCRC (1.98%) and 252 I-PCCRC (1.83%). Female sex, older age and proximal location were associated with A-PCCRC. Mutations in the PIK3CA gene were less common in A-PCCRC compared to sCRC.

Conclusion: A significant percentage of PCCRC occurred despite adequate prior colonoscopy. Missed sessile serrated lesions may contribute to many of these cases; however, further studies are required to examine possible de novo cancer as a cause of PCCRC that may involve unique biological pathways.

Background: The gender pay gap in medicine is entrenched and has a negative impact on economic growth, institutional reputation and financial success, recruitment, retention and job satisfaction of female specialists and patient care. It also discourages women from entering specialist fields of medicine. In the Australian unregulated market setting, female specialists are not simply getting paid less, they are choosing to set lower fees than their male counterparts.

Aims: We examine how implicit and explicit gender biases affect how fees are set and the potential role of price transparency in addressing the gender pay gap.

Methods: We conducted 27 semi-structured interviews with medical specialists recruited via social media and medical society newsletters between June 2021 and March 2022. Interviews were recorded and transcribed verbatim. Data were analysed using thematic analysis. Twenty surgeons and seven anaesthetists, 15 of whom identified as male and 12 as female, participated in this study. The primary outcomes and measures focused on the perspectives of surgeons and anaesthetists regarding fee-setting practices.

Results: A combination of contextual and market- and gender-related factors was the source of the biases that determine fee setting. Further, information asymmetry in medicine in Australia underlies current fee-setting practices, exacerbating and entrenching false perceptions about women's skills as surgeons and anaesthetists. Women tend to internalise these biases, self-regulating their behaviours and how they set their fees.

Conclusion: The gender pay gap is pervasive. Greater transparency on fees and quality could be explored as a potential solution to reduce pay inequality.

Background: New amyloid-targeting monoclonal antibody (mAb) therapies for Alzheimer's disease (AD) are currently under review by the Therapeutic Goods Administration for use in Australia.

Aims: To determine the infrastructure, workforce and training needs of Australian memory and cognition clinics in order to characterise health system preparedness for these therapies.

Methods: A national, cross-sectional online survey of medical specialists.

Results: Thirty medical specialists (geriatricians, n = 23; psychiatrists, n = 4; neurologists, n = 3) from 30 different clinics participated (public, 76.7%; private, 23.3%), including from metropolitan (73.3%), regional (20.0%) and rural (6.7%) areas. On average, clinics reported assessing 5.4 (SD = 3.2) new patients per week, of which 2.4 (range: 0-5) were considered to have mild cognitive impairment (MCI). Only 40% of clinics use biomarkers to assess whether patients with MCI have AD, and 45% have intravenous infusion capability. While the majority of clinicians were confident in their knowledge of mAbs, only 33% felt confident in using these. Identified impediments to clinical implementation included (i) lack of real-world experience, (ii) lack of current Models of Care and appropriate use guidelines, (iii) current clinic set-up and (iv) information about safety.

Conclusions: Australia's health system preparedness for amyloid-targeting mAb therapies will require further investment in infrastructure, equity of access, clinician training and support. Long wait times already impact access to clinics, and with the forecast rise in MCI and dementia cases, services will need to be expanded, and appropriate Models of Care and clear and efficient inter-sector health pathways will be needed to prepare for the use of mAbs.

Pain is a common presenting symptom to consultant physicians, both in the hospital and in the clinic or rooms. Biologically, pain serves as warning of tissue damage. But this is no longer the case when pain is present for months or years, especially when it has been fully investigated. There can be a substantial discrepancy between the magnitude of pain, disability and distress reported by a patient with chronic pain and the extent of tissue damage identified. From the 1990s until the mid-2010s, opioids were promoted as a safe and effective panacea for chronic non-cancer pain. This led to overprescribing with unfortunate consequences of misuse, abuse and overdose deaths. The response to the so-called ‘opioid epidemic’ has led to a renewed focus on how chronic pain should be managed. The aim of this article is to update fellows and trainees on the assessment and management of chronic pain in adult medical patients. In particular, we address the role of pharmacotherapy post-opioid epidemic (primarily antidepressants and anticonvulsants in neuropathic pain), the place of interventional procedures and the nature and effectiveness of pain self-management training in people with chronic pain, many of whom have had pain for a year or more and failed other treatments.

Anaemia is a well-recognised and widely accepted consequence of iron deficiency (ID); however, the two diagnoses are not synonymous with the effects of ID occurring long before the development of anaemia. In adults, ID can cause physical and neuropsychological symptoms, including lethargy, altered mood and poor concentration, reducing an individual's quality of life. Foetal and neonatal ID has been associated with impaired neurocognitive development with lasting effects despite iron replacement in early life. Obstetric ID is common, affecting up to 70% of Australian pregnancies. The impact, at both an individual and a population level, remains underappreciated and consensus on the identification and management of obstetric ID is lacking. This consensus statement was developed by the Haematology in Obstetrics and Women's Health (HOW) Collaborative and utilised the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to evaluate evidence and strength of recommendations. Recommendations are as follows: (i) Routine ferritin screening should be performed in all pregnant women (GRADE 1C) at booking and 24–28 weeks. Repeat testing should be performed at 36 weeks if clinically indicated or if the woman is previously unscreened. (ii) ID in pregnancy should be defined as a ferritin level <30 μg/L (GRADE 1D). (iii) An appropriate oral iron formulation should be offered as first-line therapy for obstetric ID (GRADE 1B). (iv) Alternate-day oral dosing can be considered to limit side effects in women with obstetric ID (GRADE 2B). (v) Intravenous iron should be offered to women with ID/ID anaemia who are intolerant of or refractory to oral iron or in the third trimester (GRADE 1B).