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Bulletin for 30 July 2021


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Relative benefits of blood pressure lowering on cardiovascular event
In a meta-analysis of individual participant data from 48 randomized trials, the projected estimated benefit from a 10 mmHg reduction in systolic blood pressure was a 26 percent relative reduction in risk of stroke, a 16 percent relative reduction in risk of coronary disease, and a 26 percent relative reduction in risk of heart failure [24]. (See "Cardiovascular risks of hypertension", section on 'Impact of hypertension on specific cardiovascular disorders'.)

Brain metastases in metastatic breast cancer
As patients with advanced breast cancer live longer, the incidence of brain metastases appears to be increasing, with one meta-analysis suggesting that approximately one-third of patients with HER2-positive, one-third of those with triple-negative, and 15 percent of those with hormone receptor positive, HER2-negative metastatic breast cancer will develop brain metastases [28]. (See "Brain metastases in breast cancer", section on 'Introduction' and "Epidemiology, clinical manifestations, and diagnosis of brain metastases", section on 'Clinical manifestations'.)


Cochrane library

Compression bandages or stockings versus no compression for treating venous leg ulcers
If using compression bandages or stockings, people with venous leg ulcers probably experience complete wound healing more quickly, and more people have wounds completely healed. Cochrane Database of Systematic Reviews – Intervention 26 July 2021

Non‐pharmacological interventions for preventing delirium in hospitalised nonICU patients
There is moderate‐certainty evidence regarding the benefit of multicomponent non‐pharmacological interventions for the prevention of delirium in hospitalised adults, estimated to reduce incidence by 43% compared to usual care. Cochrane Database of Systematic Reviews – Intervention 19 July 2021


Cochrane clinical answers

How do methods for managing miscarriage compare?
Evidence from network meta‐analyses (NMAs) suggests the most effective method for managing miscarriage varies depending on the outcome, although suction aspiration appears to have a very high probability of being the most likely method to achieve complete miscarriage.  Cochrane clinical answers 26 July 2021

What are the effects of prophylactic benzodiazepines, barbiturates, and anticonvulsants for management of febrile seizures in children?
Compared with placebo/no treatment, moderate‐certainty evidence shows that intermittent diazepam (oral or rectal) and continuous phenobarbital probably reduce seizure recurrence at 6 and 12 months in children with febrile seizures. Cochrane clinical answers 22 July 2021

What are the effects of early postnatal discharge from hospital for healthy mothers and term infants?
For healthy mothers and term infants, moderate‐certainty evidence shows that more infants were probably re‐admitted for neonatal morbidity within 28 days after early postnatal discharge than after standard discharge (on average, 37 vs 23 per 1000 infants). Cochrane clinical answers 22 July 2021


Evidently Cochrane

Pulmonary rehabilitation and exercise training for adults with chronic respiratory conditions
n this blog for healthcare professionals, Dr Rebecca Gould, Cochrane UK Fellow and Sport and Exercise Medicine Registrar rounds up the latest Cochrane evidence on pulmonary rehabilitation and exercise training for adults with chronic respiratory conditions. Evidently Cochrane 23 July 2021



Drug‐induced liver injury in Australia, 2009–2020: the increasing proportion of nonparacetamol cases linked with herbal and dietary supplements
In the author’s single centre study, the proportion of cases of people hospitalised with drug‐induced liver injury (DILI) linked with herbal and dietary supplements has increased since 2009. Ninety‐day transplant‐free survival for patients with non‐paracetamol DILI, especially those with supplement‐related DILI, is poorer than for those with paracetamol‐related DILI. MJA 26 July 2021

Psychotropic medicine prescribing and polypharmacy for people with dementia entering residential aged care: the influence of changing general practitioners
Increases in medicine use and rates of psychotropic dispensing were higher for people with dementia who changed GP when they entered residential care. MJA 26 July 2021 



Does depression screening in primary care improve mental health outcomes?
Instead of routinely screening all patients in primary care, engage patients in discussions about their overall wellbeing, including mental health, and be alert to clinical cues that could suggest depression. BMJ 19 July 2021



Comparison of HIV screening strategies in the emergency department: A randomized clinical trial
Targeted HIV screening was not superior to nontargeted HIV screening in the ED. Nontargeted screening resulted in significantly more tests performed, although all strategies identified relatively low numbers of new HIV diagnoses. JAMA 26 July 2021

Pathological Computed Tomography features associated with adverse outcomes after mild traumatic brain injury : A TRACK-TBI study with external validation in CENTER-TBI
In this study, pathological CT features carried different prognostic implications after mTBI to 1 year postinjury. Some patterns of injury were associated with worse outcomes than others. These results support that patients with mTBI and these CT features need TBI-specific education and systematic follow-up. JAMA 19 July 2021

Seizure prophylaxis after spontaneous intracerebral haemorrhage
This decision analytical model suggests that short-term (7-day) prophylaxis dominates longer-term therapy after sICH. Use of the 2HELPS2B score to guide clinical decisions for initiation of short-term primary vs secondary early-seizure prophylaxis should be considered for all patients after sICH. JAMA 26 July 2021

Quantifying viral particle aerosolization risk during tracheostomy surgery and tracheostomy care
Tracheostomy surgery and tracheostomy care generate substantial aerosols, but a combination of heat moisture exchanger and surgical mask coverage of the tracheostomy was associated with a significant decrease in the risk of viral transmission to health care workers. JAMA 22 July 2021


Other journals

Understanding the complexities of antibiotic prescribing behaviour in acute hospitals: a systematic review and meta-ethnography
This first meta-ethnography of doctors` experiences of antibiotic prescribing in acute hospital settings has enabled development of a novel conceptual model enhancing understanding of appropriate antibiotic prescribing. Archives of public health 23 July 2021

Importance of confirming the underlying diagnosis in patients with myocardial infarction and non-obstructive coronary arteries (MINOCA): a single-centre retrospective cohort study
Only in one-third of MINOCA patients a conclusive diagnosis for the acute presentation was identified. Recurrent Cardiac Emergency Department (CED) visits were more often observed in the indeterminate MINOCA group, while the occurrence of cardiovascular events was similar across groups. BMC Cardiovascular Disorders 28 July 2021

Neonatal mortality prediction with routinely collected data: a machine learning approach
Machine learning algorithms were able to identify with very high predictive performance the neonatal mortality risk of newborns using only routinely collected data. BMC Pediatrics 21 July 2021

Association between the use of balanced fluids and outcomes in critically ill children: a before and after study
Following a unit-wide implementation of balanced fluids as standard care, there were no differences in rates of day 3 AKI or other clinical outcomes. However, there were lower rates of hyperkalemia and hyperchloremia and higher rates of hypokalemia and hypochloremia. Critical care 29 July 2021


Clinical Key

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  • Emergency Medicine Secrets, Seventh Edition
  • Ferri's Clinical Advisor 2022


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Mental Health - What’s new? I Bulletin for  13 July 2021

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What are the ethical dilemmas in the decision-making processes of nursing people given electroconvulsive therapy? A critical realist review of qualitative evidence 
Journal of psychiatric and mental health nursing 1 July 2021 
ECT is a treatment which has a long and complicated history. There is no consensus on its effectiveness and there is a great deal of polarized debate as to whether it should be used. MHNs are asked to work with people who are receiving ECT as part of their duties. The paper seeks to move beyond the polarized arguments and to consider how MHNs can work with people where ECT is being considered or administered as part of their treatment in a manner which satisfies their professional obligations. MHNs may need to broaden their understanding of ethics beyond the traditional biomedical ethics model of beneficence, non-maleficence, justice and autonomy, as well as improving their understanding of social and political factors which may have an unseen effect of the use of ECT as a treatment in order to meet their professional obligations when working with people being administered ECT.

Every intervention emerges from an encounter: Translation and contextualisation as treatments for recurrent depression Journal of psychiatric and mental health nursing 29 June 2021 
This article is an academic anthropologist’s account of his depression’s outpatient management. In particular, I explore the treatment’s time dynamics as they were described in my psychiatrist’s letters to my General Practitioner (hereafter GP). Many good accounts of the subjective experience of depressive illness (Ratcliffe 2015, Wurtzel 2017) and some joint accounts with professionals (e.g., Lawrence & Lawrie 2012) exist.

Workplace violence and risk factors for PTSD among psychiatric nurses: Systematic review and directions for future research and practice Journal of psychiatric and mental health nursing 2 July 2021 
Psychiatric nurses are at risk of workplace violence and posttraumatic stress disorder (PTSD). There is limited understanding of pre-trauma and post-trauma risk factors. The authors reviewed factors associated with workplace PTSD in psychiatric nurses. The authors searched quantitative and qualitative studies from 1980-2019 in 23 databases plus abstracts for studies on psychiatric hospital nursing staff, potentially traumatic workplace events, workplace factors, and PTSD. Following duplicate abstract (n=10,064) and full text (n=199) screening, data were extracted in duplicate from 19 studies. Using best fit framework synthesis, we identified workplace violence, pre-trauma, and post-trauma risk factors. Six variables yielded evidence in at least two empirical studies scoring at least 6/8 on a quality measure, or one such study plus more than one other study (“promising”: severe/injurious assault, cumulative exposure, burnout, poor mental health, low compassion satisfaction, neuroticism). Four were supported by at least one better quality study or at least two others (“suggestive”: gender, poor training, any physical aggression exposure, compassion fatigue). Pre-trauma measures, consistent definitions of workplace exposures, and thorough reporting of quantitative results are needed to improve research. Violence prevention, and mental healthcare for exposed nurses, appear the most promising targets for PTSD prevention. Therefore, it is particularly important to understand workplace violence and mental health among nurses working in psychiatric hospitals.

Exploring the meaning of life from the perspective of patients with depression: A phenomenological study Archives of psychiatric nursing 1 October 2021 
This study explored the perceptions of meaning of life for patients with depression. A qualitative phenomenology approach was used. Patients with depression ( n = 20) were recruited until data saturation occurred. Findings revealed four themes all related to their value of: (1) accepting depression; (2) appreciating work (paid and non-paid); (3) embodying love and taking on responsibilities; (4) receiving spiritual comfort. Healthcare professionals could facilitate patients with depression to explore their meaning of life while enduring and transforming the emotional pain that accompanies depression, hence, perhaps, decreasing their suicidal ideations.

Occupational therapy 
Personal narratives of learning self-management: Lessons for practice based on experiences of people with serious mental illness Australian occupational therapy journal 25 June 2021 
Clinicians are challenged to deliver self-management interventions in recovery-oriented services for individuals living with serious mental illnesses. Little is known about how people learn self-management skills and questions remain about how best to deliver support. To offer insights for delivery, this research describes the lived experiences of learning self-management and the meaning of those experiences within recovery journeys and the context of health-care delivery. Design followed van Manen's approach of phenomenology through an occupational therapist's lens. Using purposeful criterion sampling until saturation, 25 adults with psychosis experiences (8-40 years) from six community-based specialised mental health programs were interviewed. Conceptual maps were cocreated depicting key learning experiences, intersections with services, and recommendations. Data reduction, reconstruction and explication of meaning occurred concurrently, and multiple strategies were used to transparently support an open, iterative, reflexive process. Participants' narratives compel increasing access to strategic personalised self-management learning opportunities as an effort to shorten the prolonged recovery paths. Findings offer ways providers can understand and address eight self-management learning tasks from the perspective of lived experiences. Self-management was enmeshed with recovery, health, and building a life.

Exploring the ideal practice for occupational therapists on assertive community treatment teams British journal of occupational therapy 25 June 2021 
This qualitative, interpretive description study involved 11 Canadian ACT team occupational therapists in one individual, semi-structured in-depth interview using an interview guide containing open-ended questions. Interview transcripts were analyzed to identify themes pertaining to therapists’ descriptions of their perceived ideal occupational therapy practice on ACT teams. Three themes emerged: (a) Engaging in practice “with intention”; (b) Finding the space for occupational therapy practice; and (c) Supporting clients in their recovery to find their best occupational self. The findings highlight practice possibilities for occupational therapist working on ACT teams and provide a foundation for advocating for better use of specific occupational therapy practices within community mental health settings.

Suicide trends in the early months of the COVID-19 pandemic: an interrupted time-series analysis of preliminary data from 21 countries The Lancet psychiatry 1 July 2021  
The purpose of this systematic review is to systematically investigate which non-pharmacological interventions are effective in reducing This is the first study to examine suicides occurring in the context of the COVID-19 pandemic in multiple countries. In high-income and upper-middle-income countries, suicide numbers have remained largely unchanged or declined in the early months of the pandemic compared with the expected levels based on the pre-pandemic period. We need to remain vigilant and be poised to respond if the situation changes as the longer-term mental health and economic effects of the pandemic unfold.

Using EEG to predict clinical response to electroconvulsive therapy in patients with major depression: A comprehensive review Frontiers in psychiatry 24 June 2021 
An important approach to improve the therapeutic effect of electroconvulsive therapy (ECT) may be to early characterize patients who are more likely to respond. The authors’ objective was to explore whether baseline electroencephalography (EEG) settings before the beginning of ECT treatment can predict future clinical response to ECT in patients with depressive disorder. The authors conducted a systematic search in the MEDLINE, EMBASE, PsycINFO, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify studies using EEG in adults with depressive disorder treated by ECT. To investigate the predictive value of baseline EEG on clinical outcomes of ECT, we extracted from the retrieved studies and qualitatively described the association between the baseline EEG markers characteristics and the rates of future responders and/or remitters to ECT. The primary search yielded 2,531 potentially relevant citations, and 12 articles were selected according to inclusion criteria. Most of the studies were prospective studies with small sample size. Sociodemographic and clinical characteristics of patients, ECT settings, EEG settings, and outcomes were heterogeneous. Event-related potential (ERP) paradigms were used in three studies, polysomnography was used in three studies, and the six other studies used EEG to measure cerebral connectivity and activity. P300 amplitude, coherence, and connectivity measures were correlated with remission in patients with depression treated by ECT. Sleep EEG recordings seemed not to be correlated with remission after ECT. Further prospective studies with large sample size are needed to determine optimal EEG parameters associated with clinical response to ECT in depressive disorder.

Improving engagement in behavioral and mental health services through animal-assisted interventions: A scoping review Psychiatric services 23 June 2021 
Client engagement in behavioral and mental health services has been strongly linked to improved outcomes and treatment completion. Animal-assisted interventions (AAIs) are increasingly used to improve client engagement, for example, by involving a dog in therapy to support a client’s sense of safety. Although existing research suggests that human-animal interactions may promote engagement, further research is needed to understand the underlying mechanisms, identify procedures needed for treatment fidelity, and determine the populations in which this intervention would be most effective. The aim was to identify the existing knowledge base to inform future research and practice in these areas. A review was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines to answer three questions: What research has been completed regarding the use of animals to affect client engagement, including measurement of potential processes of change? How have interventions that use animals been structured and protocolized? How is engagement operationally defined by these studies? Ten studies were identified for review. Preliminary evidence indicates that AAIs may support client engagement in behavioral and mental health services. A wide range of conceptualizations in which populations and settings could benefit from AAIs were identified, but it remains unclear who would benefit most. The review did not substantively address the efficacy of AAIs for increasing engagement or factors that may drive engagement. Further research is needed to quantify the impact of AAIs on service engagement and to identify mechanisms of change.

BDNF as a biomarker of cognition in schizophrenia/psychosis: An updated review Frontiers in psychiatry 16 June 2021 
Brain Derived Neurotrophic Factor (BDNF) has been linked to cognitive symptoms of schizophrenia, which has been documented in previous reviews by several authors. However, a trend has recently emerged in this field moving from studying schizophrenia as a disease to studying psychosis as a group. This review article focuses on recent BDNF studies in relation to cognition in human subjects during different stages of the psychotic process, including subjects at high risk of developing psychosis, patients at their first episode of psychosis, and patients with chronic schizophrenia. We aim to provide an update of BDNF as a biomarker of cognitive function on human subjects with schizophrenia or earlier stages of psychosis, covering new trends, controversies, current research gaps, and suggest potential future developments in the field. We found that most of current research regarding BDNF and cognitive symptoms in psychosis is done around schizophrenia as a disease. Therefore, it is necessary to expand the study of the relationship between BDNF and cognitive symptoms to psychotic illnesses of different stages and origins.

Psychosocial and lifestyle predictors of distress and well-being in people with mental illness during the COVID-19 pandemic Australasian psychiatry 30 June 2021 
People with mental illness may be vulnerable to psychological distress and reduced well-being during the COVID-19 pandemic. The aim of this study was to assess psychosocial and lifestyle predictors of distress and well-being in people with mental illness during the pandemic. People with mental illness who participated in an exercise programme prior to the pandemic were invited to complete surveys about mental health and lifestyle corresponding to before and during the pandemic. Social support reduced, alcohol intake increased, and sleep quality and diet worsened during the pandemic, contributing to distress. Psychological distress was associated with the two or more mental illnesses, and negatively associated with having a physical disease. Better diet appeared to protect against increases in distress; loneliness hindered improvements in well-being. Healthy lifestyle programmes designed to improve social connection may improve health for people with mental illnesses during and after the COVID-19 pandemic.

Neurodevelopmental effects of cannabis use in adolescents and emerging adults with ADHD: A systematic review Harvard review of psychiatry 16 June 2021 
A dearth of evidence is available on the impact of cannabis use on the developing brain and functioning for individuals with ADHD, despite the elevated risk for substance use in this population. The limited, potentially underpowered evidence does not support the hypothesis that cannabis use has a deleterious impact on neuropsychological tasks in transitional age youth with ADHD. Larger and longer-term studies are needed, however, to better inform clinicians and patients as to the impacts of cannabis use in youth with ADHD.

Evaluating the machine learning literature: A primer and user’s guide for psychiatrists The American journal of psychiatry 3 June 2021 
"Mr. A," a 24-year-old man, presents for evaluation of worsening depression. He describes a history of depression since adolescence, although he notes that he suffered a troubled childhood, including emotional neglect. He believes a recent breakup and having been denied a promotion precipitated this episode. "I'm sleeping all the time, and my body feels heavy," he adds. He also reports increased appetite, weight gain, and "urges to cut, which I have not done in years." However, he remains social and actively involved in several hobbies. He discontinued bupropion and escitalopram in the past because of "terrible headaches and irritability." Initially, you consider starting lamotrigine. However, your office recently implemented a clinical decision support system that recommends a trial of phenelzine. The patient's symptoms remit entirely on the medication suggested by the system. Curious as to how the system decided on this treatment, you download several papers on its development. 

Addressing suffering in patients with psychiatric disorders Journal of nervous and mental disease July 2021 
Patients with psychiatric disorders (as well as general medical conditions) often describe their lives in terms of suffering. Although suffering is honoured as a central focus of physicians' concerns, it is not even indexed in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Generally connoting severe, prolonged distress, suffering can be distinguished from pain, depression, and anxiety. The aims of this article are to consider whether attending to suffering per se in psychiatric patients merits attention independent of other commonly assessed psychiatric symptoms such as anxiety, depression, and conventional distress, and how targeting suffering per se might add value to psychiatric patient care. Ascertaining sources of suffering may require new types of inquiry and additional time. Well-described, evidence-informed strategies and time-honored psychotherapy techniques are available for addressing the numerous concerns that contribute to suffering. Patients with psychiatric disorders whose distinct, multidimensional sources of suffering are identified, acknowledged, and addressed may experience better treatment quality, greater treatment satisfaction, and possibly better outcomes than those whose clinicians' attention is limited to conventional psychiatric signs and symptoms.

Third-wave interventions for eating disorders in adolescence – systematic review with meta-analysis Borderline personality disorder and emotion dysregulation 14 June 2021 This review with meta-analysis was the first to evaluate the adaptation and efficacy of third-wave therapies for the treatment of ED in adolescents. The main limitation of the empirical database is that almost all studies used DBT, while other third-wave treatments lacked empirical evaluation. Despite promising evidence of a beneficial impact of DBT, none of the treatments meet the criteria for an empirically supported treatment. Due to high relapse rates, there is an urgent need for further high-quality research into alternative ED treatments. Effective early interventions in adolescence might prevent chronification and help both patients and the healthcare system in the long run.

Schema modes and their associations with emotion regulation, mindfulness, and self-compassion among patients with personality disorders Borderline personality disorder and emotion dysregulation 10 June 2021 
Using a multivariate approach (CCA), the authors identified two independent patterns of multivariate associations between maladaptive schema modes and emotion regulation strategies. The Adaptive/Non-Adaptive general personality pathology profile includes adaptive and non-adaptive schema modes and emotion regulation strategies, confirming our hypothesis that adaptive schema modes are positively associated with other adaptive schema modes and adaptive emotion regulation strategies, while negatively associated with maladaptive schema modes and non-adaptive emotion regulation strategies. This profile represents a general personality pathology, or 'p factor', which is an indicator of a broad predisposition to psychopathology. The second, Externalizing personality pathology profile, which is independent from the previous one, can be interpreted as a pattern of multivariate associations between the Impulsive, Enraged, Angry, Undisciplined, Self-Aggrandizer and Bully Attack schema modes and emotion regulation strategies grouped under three topics: disruptive consequences of negative emotions, blaming others, and a maladaptive form of self-kindness. These two personality pathology profiles may lead to a deeper understanding of the associations between schema modes and emotion regulation strategies and underlying vulnerability dimensions of personality disorders. They may help psychotherapists in their conceptualization in order to design the most appropriate interventions.

Hair-pulling does not necessarily serve an emotion regulation function in adults with trichotillomania Frontiers in psychology 5 July 2021 
Trichotillomania (TTM) has been associated with childhood trauma and perceived stress. While it has been hypothesized that hair-pulling regulate negative emotions, the relationship between childhood trauma, perceived stress, emotion regulation, and hair-pulling has not been well-studied. Fifty-six adults with TTM and 31 healthy controls completed the Childhood Trauma Questionnaire (CTQ), Perceived Stress Scale (PSS), and Difficulties in Emotion Regulation Scale (DERS). Hair-pulling severity was measured with the Massachusetts General Hospital-Hair Pulling Scale. CTQ, PSS, and DERS total scores were compared across groups using ANCOVA and the correlation between hair-pulling severity and emotion dysregulation was determined. Regression analyses were used to estimate the association of CTQ and PSS totals with DERS, and to determine whether associations between predictors and dependent variable (DERS) differed across groups. The association between perceived stress and emotion dysregulation is not specific to TTM, and there is no association between emotion dysregulation and hair-pulling severity, suggesting that key factors other than emotion dysregulation contribute to hair-pulling. Alternative explanatory models are needed.

Social work
Dynamics of sharing lived experience Schizophrenia bulletin 18 June 2021 
One of the most powerful and unique facets of being a peer specialist is having lived experience. Our lived experience is one of our primary modalities of connecting to and working with others and there are many utilizations for sharing it. There are also many nuances to knowing when and how to share lived experience and how to be effective in doing so. One important part of sharing lived experience is creating hopefulness. Research states out of all the factors that may determine someone’s outcome with mental illness, levels of hopefulness were the primary predictor in how well someone does. This means the extent to which someone is struggling and the severity of their symptoms really does not make a difference in how well they might do afterwards. Knowing this has made it incredibly important for me to share my lived experience and to create awareness that recovery does happen and I am living proof of it.

Gatekeeper training and minimum standards of competency Crisis 30 June 2021 
Gatekeeper training (GKT) is one of the most widely used suicide prevention strategies. It involves training people who are not necessarily clinicians to be able to identify people experiencing suicidality and refer them to appropriate services. While there is a dearth of research that supports the causal link between GKT and reduced suicide rates, this is likely the result of a variety of factors including training design, definitions of “gatekeepers,” differing populations in which the gatekeeper (GK) operates, and other variables that may influence suicide rates. Despite this, research suggests that GKT improves people's knowledge, skills, and confidence in helping individuals who experience suicidal ideation and enhances positive beliefs about the efficacy of suicide prevention. However, there is no consensus on GK competencies to allow differences in effectiveness between various training programs to be measured, that is, knowledge, skills and abilities, attitudes, and self-efficacy attributes expected of a person resulting from the training. This paper discusses challenges in developing GK competencies. It uses developments in suicide prevention competencies for clinicians, vocational education, and training sector competencies, as well as empirical work in GKT, to propose minimum GK competencies that may be examined for further research and evaluation of programs.

Mental health and alcohol use in young Australians during COVID-19 National Drug & Alcohol Resource Centre 
When: Thursday, 29 July 2021 - 3:00pm EST
Synopsis: This presentation will cover changes in mental health and alcohol-related harm for young Australians during COVID-19. In this webinar Dr Philip Clare will discuss the findings of two recent articles published on the Australian Parental Supply of Alcohol Longitudinal Study (APSALS) cohort, on changes in mental health and alcohol use/harms during the COVID-19 restrictions in mid 2020. Philip is a biostatistician at the Prevention Research Collaboration, with experience in addressing sources of bias in the analysis of longitudinal data. He is both a methodological and applied researcher, with particular research interests in causal inference using observational data, and substance use among adolescents and young adults.

Youth suicide prevention via smartphones: The LifeBuoy trial National Drug & Alcohol Resource Centre 
When: Thursday, 15 July 2021 - 3:00pm EST

Synopsis: This seminar will present findings from a randomised trial of a smartphone app designed to help young people manage suicidal thoughts. Young people aged 15 to 24 years have repeatedly been identified as a group requiring specific attention in suicide prevention efforts, as one of the groups least likely to seek help for suicidal crises from face-to-face mental health services. Technology-enabled solutions, including smartphone interventions, which can deliver high-fidelity therapeutic support directly into individuals hands have potential to overcome many of the structural and attitudinal barriers to receiving care among young people. The seminar will provide a background to the opportunities for digital interventions in youth and provide a taste of the efficacy and acceptability findings from a recently completed randomised controlled trial of a smartphone intervention (LifeBuoy) designed to help young people (aged 18 – 25 years) self-manage suicidal ideation. Some of the challenges and successes in carrying out the trial and next steps will be discussed.

Bulletin for July 2021

Decolonizing Indigenous health: Generating a productive dialogue to eliminate Rheumatic Heart Disease in Australia Social science and medicine 277 2021 
The authors take Rheumatic Heart Disease (RHD), a potent marker of extreme health inequity, as a case study, and critically examine RHD practitioners' perspectives regarding the factors that need to be addressed to improve RHD prevention and care.

Review of sexual health issues linked with cardiovascular disease and type 2 diabetes mellitus in Aboriginal and Torres Strait Islander males Australian Indigenous Health Bulletin 2(2) 2021
The purpose of this review is to summarise the evidence on the links between male sexual health conditions (erectile dysfunction (ED) and low testosterone) and the chronic diseases cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM), specifically to:

  • raise awareness about the links between male sexual health and CVD and T2DM for Aboriginal and Torres Strait Islander males
  • encourage the inclusion of sexual health assessments as part of a holistic approach to the healthcare of Aboriginal and Torres Strait Islander males
  • encourage healthcare providers to consider sexual health problems and impacts in the management and prevention of CVD and T2DM among Aboriginal and Torres Strait Islander males
  • encourage Aboriginal and Torres Strait Islander males, health workers and health professionals to engage in conversations about sexual health problems and impacts, especially with regards to prevention and management.

Coming of age: 21 years of providing opioid substitution treatment within an Aboriginal community-controlled primary health service Drug and alcohol review 7 July 2021

Several Aboriginal and Torres Strait Islander community controlled health services around Australia now offer OST prescription, and a small number administer slow-release buprenorphine.

Discrimination experienced by Aboriginal and Torres Strait Islander males in Australia: Associations with suicidal thoughts and depressive symptoms ANZ journal of psychiatry 13 July 2021
The author’s analyses add to evidence that discrimination is a contributor to mental health disparities between Aboriginal and Torres Strait Islander and non-Indigenous populations in Australia. Reducing discrimination ought to be considered as part of strategies to improve the social and emotional well-being of Aboriginal and Torres Strait Islander people.

Population-based utility scores for HPV infection and oropharyngeal squamous cell carcinoma among Indigenous Australians BMC public health 26 July 2021
Among a large sample of Indigenous Australians, utility for oral HPV infection and OPSCC decreased with severity of health states. Older participants, as well as males and those residing in non-metropolitan locations, had decreased utility for high-grade cytology and early invasive cancer states. Our findings are an important contribution to cost-utility and disease prevention strategies that seek to inform policies around reducing HPV infection and OPSCC among all Australians.

Reported sources of health inequities in Indigenous Peoples with chronic kidney disease: a systematic review of quantitative studies BMC public health 23 July 2021
In this systematic review with meta-synthesis, a Kaupapa Māori methodology and the David R Williams framework was used to evaluate reported causes of health differences in chronic kidney disease in Indigenous Peoples.

Prevalence of psychiatric disorders for Indigenous Australians: a population-based birth cohort study Epidemiology and psychiatric sciences early view 2021

There is significant inequality in psychiatric morbidity between Indigenous and non-Indigenous Australians across most forms of psychiatric illness that is evident from an early age and becomes more pronounced with age. SUDs are particularly prevalent, highlighting the importance of appropriate interventions to prevent and address these problems. Inequalities in mental health may be driven by socioeconomic disadvantage experienced by Indigenous individuals.

A community-led design for an Indigenous Model of Mental Health Care for Indigenous people with depressive disorders Australian and New Zealand Journal of public health 7 June 2021
A treatment model for depression must include concepts of Indigenous autonomy, identity and wellbeing. Further, treatment approaches need to incorporate Indigenous social and emotional wellbeing concepts alongside clinical treatment approaches. Any systematic approach to address the social and cultural wellbeing of Indigenous peoples must have a community-led design and delivery.

Online resources
Sexual health links with chronic disease in Aboriginal and Torres Strait Islander males [factsheet]
This fact sheet provides a number of key facts about male sexual health, with a focus on erectile dysfunction (ED) and low testosterone (LT). Importantly, it explains that these sexual problems can be a sign of cardiovascular disease (CVD) and type 2 diabetes (T2DM). It highlights the need to increase awareness of how sexual health can be linked to chronic disease among Aboriginal and Torres Strait Islander males and health professionals.

Information covered includes:

  • the prevalence of ED and LT
  • the symptoms of ED and LT
  • barriers to accessing care for sexual problems
  • recommendations to improving awareness of, and services for, sexual health for Aboriginal and Torres Strait Islander males.

Manual of resources for Aboriginal & Torres Strait Islander suicide prevention
The manual is a collection of practical resources and tools that people, both Aboriginal and Torres Strait Islander and non-Indigenous, can use to make a real difference in promoting positive mental health and social emotional wellbeing, and preventing suicide in our communities.

Community-led research: walking new pathways together
This new publication from Sydney University Press is an open-access book on research methods for partnership  with  Aboriginal communities.

Using elders’ wisdom to guide your practice (podcast)
In this episode, Aboriginal Elder Millie Penny shares her story of resilience, and how she has fought (and continues to fight) to support the needs of Aboriginal children.

Healing the past by nurturing the future (podcast)
In this podcast, Catherine Chamberlain talks about the journey she and her team has been on, in developing culturally-based supports for mothers who maybe be experiencing complex trauma during the perinatal period.

Fact sheet: social and emotional wellbeing
Transforming Indigenous Mental Health and Wellbeing This fact sheet aims to provide health professionals with an overview of the principles, domains and determinants related to Aboriginal and Torres Strait Islander perspectives of social and emotional wellbeing.

Stroke cultural awareness video
The Stroke cultural awareness video aims to provide a South Australian (SA) resource on delivering best-practice clinical and cultural care for Aboriginal and Torres Strait Islander people experiencing a stroke.

It is presented in two parts and is designed to be used by public and private hospital staff, students and registered training organisations.

This video was funded by SA Health and developed in collaboration with the University of Adelaide, the University of SA, the SA Health and Medical Research Institute and the SA Aboriginal Chronic Disease Consortium

This resource aims to support people with a disability and their families to navigate the NDIS, build capacity and to meet their goals in a culturally informed and safe way.

Social and Emotional Wellbeing
The Australian Indigenous HealthInfoNet’s existing social and emotional wellbeing (SEWB) portal has been expanded to encompass information that is based on the holistic meaning of social and emotional wellbeing for Aboriginal and Torres Strait Islander people. This new content is based on substantial evidence around models of SEWB which will provide a strengthened coverage of updated resources for both policy makers and health practitioners.

Cecelia, a Bardi Jawi woman from the Kimberley, tells her diabetes story (video)
This short video aims to raise awareness of diabetes among Aboriginal and Torres Strait Islander people.

Smoking and pregnancy (Victorian Aboriginal Health Service)
This video aims to educate people about the harms smoking can do to both pregnant women and their children.
Harms include:

  • low birth weight
  • premature birth
  • long term health challenges.

It also provides useful information about how families and communities can protect against the harms of smoke, such as:

  • creating smoke-free environments in homes and cars
  • having designated smoking areas or no smoking areas at family and community events.
  • keep babies and children away from second-hand smoke.

We can do this (South Australian Health and Medical Research Institute)
We can do this is a confidential, online resource that aims to help Aboriginal and Torres Strait Islander people reduce or stop using methamphetamine (ice) and help them to engage with health services. The resource has been designed by Aboriginal and non-Indigenous doctors, Aboriginal community members and people who have used ice before. It is free to use and can be accessed using a computer, mobile phone or tablet with an internet connection. The developers are currently recruiting participants to test the We can do this website.

Information and resources about ice for Aboriginal and Torres Strait Islander peoples (Cracks in the ice)
The development of the website was led by an expert advisory group including Aboriginal elders, researchers, and health workers together with input from Aboriginal and Torres Strait Islander community members from across Australia. They have combined new and existing content to support and empower communities who are working to address ice use and related harms. It includes information for people who use ice, their families and friends, health workers and community groups.

COVID-19 vaccination – Protect yourself against COVID-19  Australian Department of Health
This video, produced for Aboriginal and Torres Strait Islander peoples, is designed for use on social media. It explains that by getting your COVID-19 vaccine, you can protect yourself.

Indigenous health checks and follow-ups

Through Medicare, Aboriginal and Torres Strait Islander people can receive Indigenous-specific health checks from their doctor, as well as referrals for Indigenous-specific follow-up services.

  • In 2019–20, 239,000 Indigenous Australians had one of these health checks (28%).
  • The proportion of Indigenous health check patients who had an Indigenous-specific follow-up service within 12 months of their check increased from 12% to 47% between 2010–11 and 2018–19.


The report presents data on Indigenous health checks for a time period up until the end of June 2020 (i.e. overlapping with the COVID-19 period). It also includes data on telehealth MBS items that were introduced in 2020 as part of the response to COVID-19.

When inclusion means exclusion (All together now)
All together now’s report When inclusion means exclusion is an enquiry into social commentary that inclusively portrays Indigenous people and communities in Australian mainstream media.

The Productivity Commission’s new Closing the Gap data dashboard
From this Dashboard, you can access available data on the targets agreed as part of the National Agreement on Closing the Gap. To use this Dashboard, click on one of the 4 Priority Reforms or 17 socioeconomic outcome areas below. Assessments of progress for the socioeconomic targets have been made where new data are available since the baseline year. 

Infant and child mortality rates for Indigenous Australians using linked and unlinked data: Linked Perinatal, Birth, Death Data set (AIHW) 
A Linked Perinatal, Birth Death Data set was created by linking jurisdictional perinatal and birth registration records to the National Death Index to identify Indigenous under-5 deaths occurring in specified birth cohorts within jurisdictional Perinatal Data Collections. This report examines the feasibility of using this linked data collection for analysis and explores the associated methodology, data quality issues and analysis of risk factors associated with adverse pregnancy and birth outcomes.

Every BODY is Deadly (Butterfly Foundation)
In these two short videos, Aboriginal and Torres Strait Islander women Garigarra Mundine (Garra) and Felicia Foxx talk about their experiences with eating and body image concerns.

Cultural burning in New South Wales: challenges and opportunities for policy makers and Aboriginal peoples (ANU Centre for Aboriginal Economic Policy Research)
This paper maps the challenges and opportunities to support cultural land management programs in NSW.

Significant dates
Children’s Day 2021
4 August 2021 
Synopsis: National Aboriginal and Torres Strait Islander Children’s Day (Children’s Day) is our national day dedicated to celebrating Aboriginal and Torres Strait Islander children.

International Day of the World’s Indigenous People,
9 August 2021 
Synopsis: The 2021 commemoration of the International Day of the World’s Indigenous Peoples will focus on the theme “Leaving no one behind: Indigenous peoples and the call for a new social contract”

Bulletin for 5 August 2021


Association between dual use of e-cigarette and cigarette and chronic obstructive pulmonary disease: an analysis of a nationwide representative sample from 2013 to 2018 BMC pulmonary medicine volume 13 July 2021
Dual use of e-cigarette and c-cigarette is associated with COPD in males.

A clinical research priority setting study for issues related to the use of methamphetamine and emerging drugs of concern in Australia Drug and alcohol review 8 July 2021
The authors demonstrate feasibility of a structured, collaborative clinical research priority setting process.

An unknown invisible intrusion. Impact of an adult family member’s problematic substance use on family life: a meta-ethnography Drugs: education, prevention and policy 2 July 2021
This meta-ethnography aims to provide insight into how families experience family life when adult family members PSU is present.

Exploring men’s alcohol consumption in the context of becoming a father: a scoping review  Drugs: education, prevention and policy 29 July 2021
This scoping review synthesizes evidence on men’s experiences of alcohol consumption in the context of fatherhood, and on interventions to reduce drinking among new fathers.

Moral disengagement and the harms of cocaine use Drugs: education, prevention and policy 8 July 2021 
In this study the authors investigated whether people who use cocaine engage in moral disengagement (MD) strategies to reduce anticipated guilt associated with use.

Professional education to reduce provider stigma toward harm reduction and pharmacotherapy Drugs: education, prevention and policy 8 July 2021
This study suggests that education targeting prejudice and discriminatory actions against harm reduction and pharmacotherapy interventions among healthcare professionals may contribute to stigma reduction.

Cigarette pack size and consumption: an adaptive randomised controlled trial BMC public health 18 July 2021
It remains unclear whether reducing cigarette pack sizes from ≥25 to 20 cigarettes reduces cigarette consumption. Importantly, the results of this study provide no evidence that capping cigarette pack sizes would be ineffective at reducing smoking

Conceptualising hepatitis C stigma: A thematic synthesis of qualitative research International journal of drug policy 11 July 2021
Approaches to address stigma in relation to HCV must consider how stigma operates throughout social processes and is embedded in systems of power and normalised in institutional operating systems.

Cognitive-affective transdiagnostic factors associated with vulnerability to alcohol and prescription opioid use in the context of pain Alcohol research current reviews 15 July 2021
The use of alcohol and prescription opioids is common among people in pain and poses significant public health burdens. This review identifies factors associated with motivation to use alcohol and prescription opioids in the context of pain.

Associations between smoke-free vehicle legislation and childhood admissions to hospital for asthma in Scotland: an interrupted time-series analysis of whole-population data The Lancet public health 15 July 2021
Although legislation banning smoking in vehicles did not affect hospital admissions for severe asthma among children overall or in the older age group, this legislation was associated with a reduction in severe asthma exacerbations requiring hospital admission among preschool children, over and above the underlying trend and previous interventions designed to reduce exposure to second-hand smoke.

Protecting women and girls from tobacco and alcohol promotion BMJ 19 July 2021
Key messages

  • Women and girls in low and middle income countries are exposed to aggressive marketing tactics by tobacco and alcohol industries, which exploit gender inequalities and associate their products with women’s empowerment
  • A rise in the consumption of alcohol and tobacco among women and girls will lead to an increase in non-communicable diseases globally, both in the short term and among generations to come 
  • A rise in non-communicable dieases has important implications for public health and the achievement of global development goals
  • Governments and other stakeholders should tackle gender and other inequalities while improving health to protect women and girls in low and middle income countries from tobacco and alcohol promotion

Unity in diversity: A systematic review on the GHB using population International journal of drug policy Vol 94 2021
Policy interventions should aim at preventing the transition from recreational substance use to GHB use, as most users are experienced recreational substance users prior to starting GHB use. When people use GHB regularly, interventions should aim at reducing the level of GHB use and preventing GHB use-related harm. Longitudinal studies and population-based probability sampling are required for more insight in the dynamics of GHB use in different sub-populations, and the transition from one group to the other, ultimately leading to dependence on GHB.

Opioid use disorder and the brain: a clinical perspective Addiction early view 6 July 2021  
This narrative review aims to summarize the literature regarding OUD and the brain from a clinical perspective. Alterations of brain structure and function are discussed, as well as neurological and psychiatric disorders in OUD. Finally, the authors review current and new directions for assessment and treatment.

Pharmaceutical opioid poisonings in Victoria, Australia: rates and characteristics of a decade of Emergency Department presentations across nine pharmaceutical opioids Addiction 2 August 2021
In Victoria, Australia, rates and characteristics of emergency department presentations for pharmaceutical opioids show distinct variations by opioid type.

Factors associated with suicidal ideation in drug addicts based on the theory of planned behaviour BMC Psychiatry 26 July 2021
The structures of attitude, subjective norms and perceived behavioral control and intent predicted suicidal ideation in the drug addicts, so the theory of planned behavior will be a good framework for educational interventions to reduce suicide in them.

Who would try (or use more) cannabis if it were legal? Drug and alcohol review 25 July 2021 
Decriminalisation of cannabis use is likely to result in an increase in consumption of the drug among young people with mental health problems. If cannabis use is decriminalised, Australian State and Territory Governments should make provision for a possible increase in demand for drug treatment and for public education on the risks associated with frequent/prolonged cannabis use.

A wastewater-based assessment of the impact of a minimum unit price (MUP) on population alcohol consumption in the Northern Territory, Australia Addiction 20 July 2021 
Per-capita consumption of alcohol appears to have decreased substantially in the Northern Territory of Australia immediately after the implementation of a minimum unit price but consumption steadily recovered and almost returned to the pre-MUP consumption level after 15 months.

20 years of Portuguese drug policy - developments, challenges and the quest for human rights Substance abuse treatment, prevention, and policy 17 July 2021
Portugal decriminalized the public and private use, acquisition, and possession of all drugs in 2000; adopting an approach focused on public health rather than public-order priorities. Arguing that the Portuguese Drug Policy Model has not proven influential enough to emancipate drug use from the stigma that associates it either with crime or pathology, this article critically discusses the developments and current challenges the Portuguese drug policy confronts, namely the growing diversity of drug use patterns observed in Portugal as well as in Europe.

Alcohol-related suicide across Australia: a geospatial analysis ANZ journal of public health 7 June 2021
Results from this study identify areas in which prevention strategies should target alcohol use and can be used to inform prevention strategy design. Additionally, hotspots and coldspots identified in this study can be used for further analysis to better understand contextual risk factors for alcohol-related suicide.

Online resources

Understanding fetal alcohol spectrum disorder (FASD) What educators need to know. For education staff working with children and young people with FASD (NHS – UK) 
This resource provides appropriate strategies and interventions for FASD and is also applicable for use with children and young people who are not yet diagnosed with FASD, but who share some of the same learning needs.

Accessing medicinal cannabis (ADF) 1 July 2021
Demand for medicinal cannabis products continues to grow in Australia, with the Therapeutic Goods Administration (TGA) approving almost 10,000 Special Access Scheme applications in May 2021 alone


Report 13 of the National Wastewater Drug Monitoring Program
Report 13 of the National Wastewater Drug Monitoring Program (the Program) covers around 56 per cent of the Australian population, which equates to about 13.1 million people. Fifty-seven wastewater treatment plants across Australia participated in the December 2020 collection, which monitored the consumption of 12 substances. In February 2021, when only capital city sites were sampled, there were 20 sites. This is the first time the ACIC has included ketamine in the list of drugs monitored by the Program. Additional data are again available, by state and territory and drug type, as a guide to trends over the period the respective drugs have been monitored by the Program.

Drug use monitoring in Australia: Drug use among police detainees, 2020 (AIC)
The Drug Use Monitoring in Australia program involves the routine collection of survey and urinalysis data from police detainees across Australia. In 2020, almost half of the detainees reported using cannabis (47%) and methamphetamine (45%) in the past 30 days. Fewer detainees reported using benzodiazepines (21%), cocaine (8%), heroin (7%) or ecstasy (5%) in the past month. In the early stages of the COVID-19 pandemic, the availability and quality of methamphetamine and heroin declined. Past-month methamphetamine use, as confirmed by urinalysis results, also decreased from 55 percent in January–February to 38 percent in April–June.

Trends in the availability and type of drugs sold on the internet via cryptomarkets, May 2020 - May 2021 (NDARC)
This bulletin series reports on trends in the availability and type of substances sold on the internet via cryptomarkets over the last 13 months.

Use of GHB amongst sentinel samples of people who regularly use illicit drugs in Adelaide, South Australia, 2020 (NDARC) 
The aims of this bulletin are to examine i past six month use of GHB (including GBL and 1 4 BD) 1 ii) demographic, drug use and drug related behavioural characteristics of those who report GHB use, and iii) GHB overdose, among two sentinel samples of people who regularly use illicit drugs in Adelaide, South Australia, with a specific focus on data collected in 2020 The latter two aims concentrate on data collected from one sentinel sample of people who regularly inject drugs

Declines in methamphetamine supply and demand in Australia during the COVID-19 pandemic (AIC) 
This study uses data from the Drug Use Monitoring in Australia program to examine the impact of the COVID-19 pandemic on the methamphetamine market in Australia. Since the pandemic began, the availability and quality of methamphetamine have decreased, prices have increased (from $17.50–$50 per point to $50–$250 per point) and consumption has declined. The impact of the pandemic varied by location, with more disruption observed in Perth relative to Brisbane and Adelaide. The COVID-19 pandemic appears to have restricted the supply of methamphetamine in Australia, resulting in higher prices and lower consumption of the drug.

Impact of the COVID-19 pandemic on cannabis demand and supply in Australia (AIC)
This study uses data from the Drug Use Monitoring in Australia program to examine the impact of the COVID-19 pandemic on cannabis demand and supply in Australia. It found past-month cannabis users reported using cannabis on a median of 25 days per month, significantly more often than before the pandemic. Those experiencing changes in their employment, financial or living situation or mental health or who used drugs to cope with negative emotions were more likely to increase cannabis use. Most users reported no changes in cannabis supply, but there were increasing prices and decreasing numbers of dealers in Brisbane.

E-Cigarettes and Vaping- What you need to know (Positive choices)
This webinar is for school staff, parents, health professionals, and youth who are seeking information on electronic cigarettes (e-cigarettes) and vaping.

Mental health and alcohol use in young Australians during COVID-19 (NDARC)
This presentation covered changes in mental health and alcohol-related harm for young Australians during COVID-19.

Updated 5 August 2021

Audio interview: Looking back and looking forward — Part 2
In this audio interview conducted on July 28, 2021, the editors continue to discuss what we’ve learned about Covid-19 and how to apply those lessons in the future. NEJM 5 August 2021

Should covid vaccination be mandatory for health and care staff?
New English law will make vaccination a condition of employment for eligible care home workers, following similar moves in Italy, France, and Greece for healthcare staff. This is reasonable, argues Michael Parker, because care institutions have a duty to protect patients; but Helen Bedford, Michael Ussher, and Martine Stead worry that such a blunt approach is unnecessary and could be counterproductive. BMJ 4 August 2021

Mucormycosis after COVID-19 in a patient with diabetes
COVID-19 followed by mucormycosis carries a very high mortality rate and timely detection, antifungal therapy, and aggressive surgical debridement remain key factors in the management. The Lancet 4 August 2021

Subcutaneous REGEN-COV antibody combination to prevent Covid-19
Subcutaneous REGEN-COV prevented symptomatic Covid-19 and asymptomatic SARS-CoV-2 infection in previously uninfected household contacts of infected persons. Among the participants who became infected, REGEN-COV reduced the duration of symptomatic disease and the duration of a high viral load. NEJM 4 August 2021

Therapeutic anticoagulation with Heparin in critically ill patients with Covid-19
In critically ill patients with Covid-19, an initial strategy of therapeutic-dose anticoagulation with heparin did not result in a greater probability of survival to hospital discharge or a greater number of days free of cardiovascular or respiratory organ support than did usual-care pharmacologic thromboprophylaxis. NEJM 4 August 2021

Therapeutic anticoagulation with Heparin in noncritically ill patients with Covid-19
In noncritically ill patients with Covid-19, an initial strategy of therapeutic-dose anticoagulation with heparin increased the probability of survival to hospital discharge with reduced use of cardiovascular or respiratory organ support as compared with usual-care thromboprophylaxis. NEJM 4 August 2021

Myocarditis and pericarditis after vaccination for COVID-19
Two distinct self-limited syndromes, myocarditis and pericarditis, were observed after COVID-19 vaccination. Myocarditis developed rapidly in younger patients, mostly after the second vaccination. Pericarditis affected older patients later, after either the first or second dose. JAMA 4 August 2021

“Hidden” cost of the pandemic: drug overdose deaths
The covid-19 pandemic was directly responsible for about 375 000 US deaths in 2020, but many drug overdose deaths were also covid related, as drug rehabilitation programmes shut down, unemployment soared, and social distancing made overdose rescues (with drugs such as naloxone) less likely. BMJ 4 August 2021

Variation of national and international guidelines on respiratory protection for health care professionals during the COVID-19 pandemic
Over the course of the COVID-19 pandemic, contextual factors (eg, resource limitations) may have generated variability in recommendations owing to a lack of scientific evidence. Inconsistencies in respiratory protection guidelines between neighboring countries created confusion over optimal measures. Strong collaborations between national and international organizations are critical in such circumstances. JAMA 4 August 2021

Intellectual property waiver for covid-19 vaccines will advance global health equity
This article argues that a temporary intellectual property waiver for covid-19 vaccines is vital to increase supply, achieve global herd immunity, and advance global health equity. BMJ 3 August 2021

Ongoing citations of a retracted study involving cardiovascular disease, drug therapy, and mortality in COVID-19
The author’s findings challenge authors, peer reviewers, journal editors, and academic institutions to do a better job of addressing the broader issues of ongoing citations of retracted scientific studies and protecting the integrity of the medical literature. JAMA 2 August 2021

Sydney avoids 4000 cases, but lockdown must be broadened
Two things are likely to significantly reduce the time to the end of lockdown: first, that everyone follows the current restrictions in place and where necessary receive the appropriate supports to help them do so.  Second, that people get vaccinated as soon as a vaccine is available.  There is a lot at stake: saving lives, the health and economic well-being of the residents of Sydney and NSW and diminishing the threat of SARS-CoV-19 export to the rest of the Australian population. MJA Insight 2 August 2021

Moral injury in clinicians concerning in COVID-19 “war”
Comparisons of clinical settings with war zones have proliferated over the past 18 months, as health care systems in many countries struggled to cope with the ravages of the COVID-19 pandemic. Clinicians and policymakers have had to make agonising decisions around allocation of care and restriction of freedoms. For the sake of clinicians, and ultimately their patients, we need to find better ways to fight the battles ahead. MJA Insight 2 August 2021

The effect of COVID-19 isolation measures on the cognition and mental health of people living with dementia: A rapid systematic review of one year of quantitative evidence
COVID-19 isolation measures have damaged the cognitive and mental health of people with dementia across the world. It is urgent to issue guidance that balances infection control measures against the principles of non-maleficence to guarantee fair and appropriate care during pandemic times for this population. EClinicalMedicine 31 July 2021

Cerebral venous thrombosis and portal vein thrombosis: A retrospective cohort study of 537,913 COVID-19 cases
A total of 537,913 patients with a COVID-19 diagnosis were included. The incidence of CVT in the two weeks after a COVID-19 diagnosis was 42.8 per million people. This was significantly higher than in a matched cohort of people who received an mRNA vaccine and patients with influenza. The incidence of PVT after COVID-19 diagnosis was 392.3 per million people. This was significantly higher than in a matched cohort of people who received an mRNA vaccine and patients with influenza. EClinicalMedicine 31 July 2021

Association of simulated COVID-19 policy responses for social restrictions and lockdowns with health-adjusted life-years and costs in Victoria, Australia
In this simulation modeling economic evaluation of estimated SARS-CoV-infection rates, time under 5 stages of restrictions, health-adjusted life-years (HALYs), health expenditure, and gross domestic product (GDP) losses in Victoria, Australia, an elimination strategy was associated with the least health losses and usually the fewest GDP losses. JAMA 31 July 2021

Assessment of video capsule endoscopy in the management of acute gastrointestinal bleeding during the COVID-19 pandemic
The results of this study suggest that video capsule endoscopy can serve as a safe alternative to the standard endoscopic evaluation of gastrointestinal bleeding because it reduces the number of invasive procedures, personnel involved, and use of personal protective equipment. JAMA 30 July 2021

Clinical, immunological and virological SARS-CoV-2 phenotypes in obese and non-obese military health system beneficiaries
Obesity is a strong correlate of COVID-19 severity in Military Health System (MHS) beneficiaries. These findings offer new pathophysiological insights into the relationship between obesity and COVID-19 severity. Annals of infectious diseases 31 July 2021

SARS-CoV-2 normalized viral loads and subgenomic RNA detection as tools for improving clinical decision-making and work reincorporation
Normalized viral loads (NVL) and Subgenomic RNA (sgRNA) are two rapid accessible techniques that could be easily implemented in routine hospital practice providing a useful proxy for viral infectivity and COVID-19 patient follow-up. Annals of infectious diseases 30 July 2021

Risk of acute myocardial infarction and ischaemic stroke following COVID-19 in Sweden: a self-controlled case series and matched cohort study
The author’s findings suggest that COVID-19 is a risk factor for acute myocardial infarction and ischaemic stroke. This indicates that acute myocardial infarction and ischaemic stroke represent a part of the clinical picture of COVID-19, and highlights the need for vaccination against COVID-19. The Lancet 29 July 2021

Early detection of COVID-19 in the UK using self-reported symptoms: a large-scale, prospective, epidemiological surveillance study
Early detection of SARS-CoV-2 infection is feasible with our model. Such early detection is crucial to contain the spread of COVID-19 and efficiently allocate medical resources. The Lancet digital health 29 July 2021

Self-reported memory problems 8 months after COVID-19 infection
We examined the prevalence of self-reported memory problems in a large group of COVID-19 patients who were not hospitalized and had a relatively mild disease. Eight months after the positive SARS-CoV-2 test, the prevalence of memory problems in this group was higher than in the control group with a negative test or in the untested control population. JAMA 29 July 2021

Presumed SARS-CoV-2 viral particles in the human retina of patients with COVID-19
The present observations show presumed SARS-CoV-2 viral particles may reach the various layers of the human retina and also could be associated with this infection’s ocular clinical manifestations. JAMA 29 July 2021

The LGBTQ+ communities and the COVID-19 pandemic: a call to break the cycle of structural barriers
The authors aim to demonstrate that the familiar patterns of LGBTQ+ health disparities reflect a perpetuating, deeply rooted cycle of injustice imposed on LGBTQ+ people. They contextualize COVID-19 inequities through the history of the HIV/AIDS crisis, describe manifestations of LGBTQ+ structural oppression exacerbated by the pandemic, and provide recommendations for medical professionals and institutions seeking to reduce health inequities. Journal of infectious diseases 29 July 2021

Coronavirus (COVID-19) vaccination information must pay attention to health literacy: analysis of readability of official COVID-19 public health information
This paper analyses the readability of official COVID-19 public health information, specifically comparing vaccination information to physical distancing and mask information. We assessed understandability and instruction clarity (actionability) for standard online content and ‘easy read’ resources. COVID-19 vaccination information performed poorly on all readability metrics which may have implications for vaccine confidence. MJA 29 July 2021

Tofacitinib in patients hospitalized with Covid-19 pneumonia
Among patients hospitalized with Covid-19 pneumonia, tofacitinib led to a lower risk of death or respiratory failure through day 28 than placebo. NEJM 29 July 2021

Audio interview: Looking back and looking forward
In this audio interview conducted on July 27, 2021, the editors look at what we’ve learned, what we’ve endured, and how we can plan for the future. NEJM 29 July 2021

Serologic surveillance and phylogenetic analysis of SARS-CoV-2 infection among hospital health care workers
These findings suggest that transmission of SARS-CoV-2 between HCWs deserves more consideration in infection prevention practice. JAMA 28 July 2021

Association of facial pustular neutrophilic eruption with messenger RNA–1273 SARS-CoV-2 vaccine
Multiple cutaneous reactions to the messenger RNA (mRNA)–1273 SARS-CoV-2 vaccine have been reported, including immediate injection site reactions, delayed injection site reactions, and localized facial/lip swelling in prior dermal filler injection sites. We report a facial eruption that developed within 24 hours after receiving the mRNA-1273 vaccine in 2 patients without a history of known allergies, rosacea, facial/dental fillers, or prior SARS-CoV-2 infection. JAMA 28 July 2021

Effect of targeted behavioral science messages on COVID-19 vaccination registration among employees of a large health system: A randomized trial
This randomized trial evaluates whether individually addressed emails designed with behaviorally informed features increase COVID-19 vaccination rates. JAMA 28 July 2021

Covid-19 breakthrough infections in vaccinated health care workers

Among fully vaccinated health care workers, the occurrence of breakthrough infections with SARS-CoV-2 was correlated with neutralizing antibody titers during the peri-infection period. Most breakthrough infections were mild or asymptomatic, although persistent symptoms did occur. NEJM 28 July 2021

Association between mood disorders and risk of COVID-19 infection, hospitalization, and death: A systematic review and meta-analysis
These results suggest that individuals with mood disorders should be categorized as an at-risk group for COVID-19 hospitalization and death, providing basis for vaccine prioritization. JAMA 28 July 2021

Diagnostic accuracy of rapid antigen tests in asymptomatic and presymptomatic close contacts of individuals with confirmed SARS-CoV-2 infection: cross sectional study
The sensitivities of both rapid antigen tests in asymptomatic and presymptomatic close contacts tested on day 5 onwards after close contact with an index case were more than 60%, increasing to more than 85% after a viral load cut-off was applied as a proxy for infectiousness. BMJ 27 July 2021

Assessment of the performance consistency of an adverse outcome prediction tool for patients hospitalized with COVID-19
Applying a previously validated model to 2892 new COVID-19 admissions in the same 6 hospitals, the authors found that model performance decreased only modestly from the initial validation study. JAMA 27 July 2021

Association between mental health disorders and mortality among patients with COVID-19 in 7 countries : A systematic review and meta-analysis
These findings suggest that patients with COVID-19 and mental health disorders should be targeted as a high-risk population for severe forms of COVID-19, requiring enhanced preventive and disease management strategies. JAMA 27 July 2021

Doxycycline for community treatment of suspected COVID-19 in people at high risk of adverse outcomes in the UK (PRINCIPLE): a randomised, controlled, open-label, adaptive platform trial
In patients with suspected COVID-19 in the community in the UK, who were at high risk of adverse outcomes, treatment with doxycycline was not associated with clinically meaningful reductions in time to recovery or hospital admissions or deaths related to COVID-19, and should not be used as a routine treatment for COVID-19. The Lancet respiratory medicine 27 July 2021

Long covid—mechanisms, risk factors, and management
This review summarizes studies of the long term effects of covid-19 in hospitalized and non-hospitalized patients and describes the persistent symptoms they endure. Risk factors for acute covid-19 and long covid and possible therapeutic options are also discussed. BMJ 26 July 2021

Safety, tolerability, and immunogenicity of an aerosolised adenovirus type-5 vector-based COVID-19 vaccine (Ad5-nCoV) in adults: preliminary report of an open-label and randomised phase 1 clinical trial
Aerosolised Ad5-nCoV is well tolerated, and two doses of aerosolised Ad5-nCoV elicited neutralising antibody responses, similar to one dose of intramuscular injection. An aerosolised booster vaccination at 28 days after first intramuscular injection induced strong IgG and neutralising antibody responses. The efficacy and cost-effectiveness of aerosol vaccination should be evaluated in future studies. The Lancet infectious diseases 26 July 2021

Safety evaluation of the second dose of messenger RNA COVID-19 vaccines in patients with immediate reactions to the first dose
This multisite US study supports the safety of Pfizer-BioNTech or Moderna vaccine second dose administration in patients who report immediate and potentially allergic reactions after the first dose. JAMA 26 July 2021

MJA Podcasts 2021 Episode 30: Communicating to patients and the public about COVID-19 vaccine safety, with Prof Julie Leask
Professor Julie Leask is a social scientist and professor in the Susan Wakil School of Nursing and Midwifery at the University of Sydney. She is affiliated with the School of Public Health and Marie Bashir Institute for Infectious Diseases and Biosecurity and is visiting professorial fellow at the National Centre for Immunisation Research and Surveillance. She talks about public health messaging and how people make decisions about vaccines. MJA 26 July 2021

Higher viral load drives infrequent SARS-CoV-2 transmission between asymptomatic residence hall roommates
This analysis argues that inter-roommate transmission occurs infrequently in residence halls and provides strong correlative evidence that viral load is proportional to transmission probability. Journal of infectious diseases 24 July 2021

Antibody response after a third dose of the mRNA-1273 SARS-CoV-2 vaccine in kidney transplant recipients with minimal serologic response to 2 doses
This study found that a third dose of mRNA-1273 vaccine induced a serologic response in 49% of kidney transplant recipients who did not respond after 2 doses. JAMA 23 July 2021

Immediate effect of the COVID-19 pandemic on patient health, health-care use, and behaviours: results from an international survey of people with rheumatic diseases
People with rheumatic disease maintained therapy and followed public health advice to mitigate the risks of COVID-19. Substantial employment status changes occurred, with potential implications for health-care access, medication affordability, mental health, and rheumatic disease activity. The Lancet rheumatology 22 July 2021

Anosmia, ageusia, and other COVID-19-like symptoms in association with a positive SARS-CoV-2 test, across six national digital surveillance platforms: an observational study
The strong association of anosmia–ageusia with self-reported positive SARS-CoV-2 test was consistently observed, supporting its validity as a reliable COVID-19 signal, regardless of the participatory surveillance platform, country, phase of illness, or testing policy. The Lancet digital health 22 July 2021

Humoral and cellular immunity to SARS-CoV-2 vaccination in renal transplant versus dialysis patients: A prospective, multicenter observational study using mRNA-1273 or BNT162b2 mRNA vaccine
Dialysis patients exhibit a remarkably high seroconversion rate of 95% after boost vaccination, while humoral response is impaired in the majority of transplant recipients. Immunosuppressive drug number and type as well as vaccine type (BNT162b2) are major determinants of seroconversion failure in both dialysis and transplant patients suggesting immune monitoring and adaption of vaccination protocols. The Lancet regional health 22 July 2021

What’s new at this update
WHO recommends IL-6 inhibitors for severe or critical disease

  • The World Health Organization strongly recommends IL-6 inhibitors (tocilizumab or sarilumab) in patients with severe or critical disease in the most recent update to its COVID-19 therapeutics living guideline.
  • The recommendation is based on high-certainty evidence that shows IL-6 inhibitors reduce mortality and the need for mechanical ventilation in these patients.
  • See the Treatment algorithm section for more information.

EMA warns of possible link between AstraZeneca vaccine and Guillain-Barre syndrome

  • The European Medicines Agency’s safety committee has recommended a change to the product information of the AstraZeneca vaccine to include a warning about cases of Guillain-Barre syndrome reported following vaccination. At this stage the available data neither confirm nor rule out a possible association with the vaccine.
  • The UK’s Medicines and Healthcare products Regulatory Agency is also reviewing these cases to assess, and based on the available evidence at this stage, the agency is not able to confirm or rule out a causal relationship.
  • See the Prevention section for more information.

EMA warns of link between mRNA vaccines and myocarditis/pericarditis

  • The European Medicines Agency’s safety committee has concluded that myocarditis and pericarditis can occur in very rare cases following vaccination with mRNA vaccines. The committee is recommending listing myocarditis and pericarditis as adverse effects in the product information, as well as a warning for healthcare professionals to be alert for signs and symptoms.
  • See the Prevention section for more information.

US guideline currently recommends against use of bamlanivimab/etesevimab

  • The US National Institutes of Health guidelines panel has updated its guidance to now recommend against the use of bamlanivimab/etesevimab at this time due to circulation of variants of concern, which have reduced susceptibility to this treatment.
  • See the Emerging section for more information.

BMJ 22 July 2021

Covid-19: The UK’s political gamble that bodes ill for health and the health service
The UK government is already inviting fear, anger, and lessons in pandemic management from home critics and the international community for its cavalier “freedom day” experiment that risks “recklessly exposing millions of people to the acute and long term effects of mass infection” BMJ 22 July 2021

Incidence of axillary adenopathy in breast imaging after COVID-19 vaccination
While the incidence of COVID-19 vaccine-induced adenopathy in our study appeared to be low at 3% compared with 16% of self-reported axillary swelling in previous COVID-19 vaccine trials, this incidence is still higher than axillary adenopathy in otherwise normal mammography, which was reported as 0.02% to 0.04%. Therefore, routine inquiring about recent history of COVID-19 vaccination is warranted. JAMA 22 July 2021

Placental expression of ACE2 and TMPRSS2 in maternal SARS-CoV-2 infection: are placental defenses mediated by fetal sex?
Sex differences in placental TMPRSS2 but not ACE2 were observed in the setting of maternal SARS-CoV-2 infection. These findings may have implications for offspring vulnerability to placental infection. Journal of infectious diseases 22 July 2021

Is SARS-CoV-2 infection a risk factor for early pregnancy loss? ACE2 and TMPRSS2 co-expression and persistent replicative infection in primitive trophoblast
Co-expression of ACE2 and TMPRSS2 in early human embryonic stem cell-derived trophoblast and the robust and replicative infection limited to syncytiotrophoblast equivalents support the hypothesis that increased viral susceptibility may be a defining characteristic of primitive trophoblast. Potential implications of these findings for early pregnancy loss deserve further investigation. Journal of infectious diseases 22 July 2021

Prevention and attenuation of Covid-19 with the BNT162b2 and mRNA-1273 vaccines
Authorized mRNA vaccines were highly effective among working-age adults in preventing SARS-CoV-2 infection when administered in real-world conditions, and the vaccines attenuated the viral RNA load, risk of febrile symptoms, and duration of illness among those who had breakthrough infection despite vaccination. NEJM 22 July 2021

Effectiveness of Covid-19 vaccines against the B.1.617.2 (Delta) variant
Only modest differences in vaccine effectiveness were noted with the delta variant as compared with the alpha variant after the receipt of two vaccine doses. Absolute differences in vaccine effectiveness were more marked after the receipt of the first dose. This finding would support efforts to maximize vaccine uptake with two doses among vulnerable populations. NEJM 21 July 2021

Dapagliflozin in patients with cardiometabolic risk factors hospitalised with COVID-19 (DARE-19): a randomised, double-blind, placebo-controlled, phase 3 trial
In patients with cardiometabolic risk factors who were hospitalised with COVID-19, treatment with dapagliflozin did not result in a statistically significant risk reduction in organ dysfunction or death, or improvement in clinical recovery, but was well tolerated. The Lancet diabetes and endocrinology 21 July 2021

Household transmission of SARS-CoV-2 from children and adolescents
This retrospective study showed that the efficient transmission of SARS-CoV-2 from school-age children and adolescents to household members led to the hospitalization of adults with secondary cases of Covid-19. NEJM 21 July 2021

Inter-subject variation in ACE2 protein expression in human airway epithelia and its relationship to SARS-CoV-2 infection
The author’s results highlight the relative importance of additional host factors, beyond viral receptor expression, in determining COVID-19 lung disease outcomes. Journal of infectious diseases 21 July 2021