Representation of Women and Women's Health in Australian Medical School Course Outlines, Curriculum Requirements, and Selected Core Clinical Textbooks.

Background: Historically, medical research has, outside of reproductive health, neglected the health needs of women. Medical studies have previously excluded female participants, meaning research data have been collected from males and generalized to females. Knowledge gained from research is translated to clinical education and patient care, and female exclusion may result in gaps in the medical school curricula and textbooks. Materials and Methods: This study involved a desktop review of the Australian Medical Council Standards for assessment and accreditation of primary medical programs, the online publicly available Australian medical school course outlines, and finally, an analysis of the recommended textbooks. Results: There is no fixed or explicit requirement to include women's health in Australian medical school curricula. Medical school course outlines do not adequately include women's health; similarly, clinical medicine textbooks do not account for sex and gender differences. Conclusion: Important sex and gender differences in medicine are not reflected adequately in the medical school course outlines, curricula, or clinical textbooks. This may have significant consequences on women's health.

Effect of experimental hookworm infection on insulin resistance in people at risk of type 2 diabetes.

The reduced prevalence of insulin resistance and type 2 diabetes in countries with endemic parasitic worm infections suggests a protective role for worms against metabolic disorders, however clinical evidence has been non-existent. This 2-year randomised, double-blinded clinical trial in Australia of hookworm infection in 40 male and female adults at risk of type 2 diabetes assessed the safety and potential metabolic benefits of treatment with either 20 (n = 14) or 40 (n = 13) Necator americanus larvae (L3) or Placebo (n = 13) (Registration ACTRN12617000818336). Primary outcome was safety defined by adverse events and completion rate. Homoeostatic model assessment of insulin resistance, fasting blood glucose and body mass were key secondary outcomes. Adverse events were more frequent in hookworm-treated participants, where 44% experienced expected gastrointestinal symptoms, but completion rates were comparable to Placebo. Fasting glucose and insulin resistance were lowered in both hookworm-treated groups at 1 year, and body mass was reduced after L3-20 treatment at 2 years. This study suggests hookworm infection is safe in people at risk of type 2 diabetes and associated with improved insulin resistance, warranting further exploration of the benefits of hookworms on metabolic health.

Evidence-Based Medicine: Feminist Criticisms and Implications for Women's Health.

Evidence-based medicine (EBM) dates back to 19th-century Paris and started out as a new paradigm for practicing medicine, with the aim of replacing anecdote with high-quality evidence from positivist-style research. Despite the clear logic underpinning EBM, there have been numerous criticisms, including maintenance of an archaic view of evidence as "facts," failure to acknowledge that all research is underpinned by the beliefs of the researcher, and the simple fact that medical research has historically been androcentric and results generalized to female patients. In this essay, we discuss the criticisms of EBM, with a focus on feminist critiques based on three central feminist epistemologies: feminist empiricism, standpoint theory, and social constructivism. We argue that EBM potentially perpetuates gaps in women's health and advocate for incorporating feminist epistemologies into future medical research to garner further understanding of social influences on women's health. In addition, we argue that EBM may degrade the clinical acumen and that critical thinking should become a key component of medical school curricula.

Self-Reported Time to Diagnosis and Proportions of Rediagnosis in Female Patients with Chronic Conditions in Australia: A Cross-sectional Survey.

Background: The diagnosis of chronic conditions in women is complicated by the historical androcentricity in medical research. Sex and gender gaps in health research may translate to unequal healthcare for women. This cross-sectional survey study aimed to ascertain the median time to diagnosis, proportions of rediagnosis and time to rediagnosis for Australian women with chronic conditions. Methods: An online survey collected anonymous data from voluntary participants. Data were analyzed using Stata14. Cox Proportional Hazards model was used to analyze time to diagnosis and rediagnosis. Logistic regression analysis was used to assess the significance of rediagnosis rates by diagnosis, age at diagnosis, income, employment, state of residence, disability status, and Indigenous status. Results: The median time from first appointment to initial diagnosis was 6 months (range 1 day-50 years) (interquartile range [IQR] 3.74 years). The median time to rediagnosis was 4 years (IQR 9) with a range of 1 day-43 years. Almost half of the women (n = 161/343, 47%) reported their primary condition being rediagnosed. From the complete responses, 40% were rediagnosed from one organic condition to another organic condition, however, 32% of women originally diagnosed with psychological, medically unexplained syndromes, or chronic pain were later rediagnosed with organic conditions. Conclusion: Median wait times for a diagnosis for women in Australia, when factoring in high rates of rediagnosis and time to rediagnosis, was 4 years. It is important that clinicians are aware of the high rediagnosis rates in female patients with chronic conditions and understand the potential impact of systemic biases on the diagnostic process for women under their care.

Mind the Gap: Reporting and Analysis of Sex and Gender in Health Research in Australia, a Cross-Sectional Study.

Introduction: Historically, medical studies have underrepresented female participants and most research data have been collected from males and generalized to other genders. This article aims to determine if there is a sex and/or gender gap in recent Australian health research. Methods: This descriptive cross-sectional study of the published literature examines recent Australian-based clinical trials for inclusion of sex and gender. Medians and interquartile ranges (IQRs) were calculated for study sample sizes and female:male representation. Proportion of sex and/or gender was analyzed by the clinical specialty of the trials. t-Tests were used to ascertain significance of any difference in recruitment of female and males. Results: A total of 88 articles were included in the analysis. Most studies (n = 63) were randomized clinical controlled trials. Overall women constituted 55% (IQR 30% of all participants). Of the 71 mixed-sex studies, only 8.9% (n = 7) analyzed the data by sex. Women were significantly underrepresented in cardiology and nephrology studies and overrepresented in psychiatry, care of the elderly, and orthopedic studies. Conclusions: When analyzed by specialty, women are overrepresented in specialties considered to be female patient dominated, such as psychiatry and care of the elderly, and underrepresented in specialties such as cardiology and nephrology. The overrepresentation of women in some specialties can reinforce gender stereotypes, potentially harming women. In addition, exclusion of males from these areas of research may be of disservice to men's health.

A complex increase in hepatitis C virus in a correctional facility: bumps in the road.

OBJECTIVE: The prevalence of hepatitis C virus (HCV) in correctional facilities in Australia among people who inject drugs is 60%, with disproportionate effects observed in Aboriginal and Torres Strait Islander people. Following the micro-elimination of HCV in a Queensland correctional facility (QCF), newly acquired cases began to increase in mid-2019. Here we discuss the public health response to increasing HCV in a QCF. METHODS: Enhanced surveillance was performed to obtain contextual outbreak data on risk factors including injecting drug use, sharing of personal hygiene equipment and do-it-yourself-tattooing. RESULTS: In the sixteen months, there were 250 notifications of new and re-infected HCV infections in prisoners in the QCF. Qualitative data revealed the leading factor in transmission to be injecting drug use. CONCLUSIONS: Drivers for increased HCV transmission in correctional facilities include boredom, waiting lists for opioid substitution programs, changes in injecting behaviours and sharing of injecting paraphernalia. Point-of-care testing combined with education and the development of a needle and syringe program may be promising ways forward for managing HCV in correctional facilities. IMPLICATIONS FOR PUBLIC HEALTH: Correctional facilities are key locations to target sexually transmitted infection (STI) and blood-borne virus (BBV) testing and treatment as well as health promotion to improve the health of inmates and the communities they return to.

Sex Inequalities in Medical Research: A Systematic Scoping Review of the Literature.

Background: Historically, medical studies have excluded female participants and research data have been collected from males and generalized to females. The gender gap in medical research, alongside overarching misogyny, results in real-life disadvantages for female patients. This systematic scoping review of the literature aims to determine the extent of research into the medical research sex and gender gap and to assess the extent of misogyny, if any, in modern medical research. Methods: Initial literature searches were conducted using PubMed, Science Direct, PsychINFO and Google Scholar. Articles published between January 01, 2009, and December 31, 2019, were included. An article was deemed to display misogyny if it discussed the female aesthetic in terms of health, but did not measure health or could not be utilized to improve clinical practice. Results: Of the 17 included articles, 12 examined the gender gap in medical research and 5 demonstrated misogyny, assessing female attractiveness for alleged medical reasons. Females remain broadly under-represented in the medical literature, sex and gender are poorly reported and inadequately analyzed in research, and misogynistic perceptions continue to permeate the narrative. Conclusion: The gender gap and misogynistic studies remain present in the contemporary medical literature. Reasons and implications for practice are discussed.

"I Just Want to Feel Safe Going to a Doctor": Experiences of Female Patients with Chronic Conditions in Australia.

Background: The androcentric history of medicine and medical research has led to an ongoing sex and gender gap in health research and education. Sex and gender gaps in research and education may translate into real-life health inequities for women. This study aimed to explore the experiences of female patients with chronic health conditions in the Australian health system, considering existing sex and gender gaps in medicine. Methods: This qualitative study used semistructured in-depth interviews with a sample of adult women with chronic conditions in Australia. Thematic analysis was undertaken, guided by Braun and Clarke. Software NVivoX64 assisted in the management of the data. Coding was performed before grouping into subthemes and central themes. To allow for potential researcher biases, the principal researcher engaged in the practice of reflexivity, including the writing of detailed notes during analysis. Results: Twenty adult Australian women with chronic conditions were interviewed. Diagnoses were varied and included Ehlers-Danlos syndrome, chronic fatigue syndrome, functional neurological disorder, and inflammatory bowel disease. Four central themes emerged: diagnostic difficulties; spectrum of health care experiences; understanding medical complexity; and coping with symptoms. Conclusions: Women with chronic conditions in Australia report pain, fatigue, and suffering that significantly impacts upon their daily lives. There was a shared experience of feeling that the pain and suffering of women was dismissed or not taken seriously. Many women expressed trauma because of their experiences in health care and often this led to a fear of accessing health services. The participants highlighted a need for more knowledge, understanding, and empathy from health care practitioners.

Outbreak of multi-drug-resistant (MDR) Shigella flexneri in northern Australia due to an endemic regional clone acquiring an IncFII plasmid.

Epidemiological surveillance of Shigella spp. in Australia is conducted to inform public health response. Multi-drug resistance has recently emerged as a contributing factor to sustained local transmission of Shigella spp. All data were collected as part of routine public health surveillance, and strains were whole-genome sequenced for further molecular characterisation. 108 patients with an endemic regional Shigella flexneri strain were identified between 2016 and 2019. The S. flexneri phylogroup 3 strain endemic to northern Australia acquired a multi-drug resistance conferring blaDHA plasmid, which has an IncFII plasmid backbone with virulence and resistance elements typically found in IncR plasmids. This is the first report of multi-drug resistance in Shigella sp. in Australia that is not associated with men who have sex with men. This strain caused an outbreak of multi-drug-resistant S. flexneri in northern Australia that disproportionality affects Aboriginal and Torres Strait Islander children. Community controlled public health action is recommended.

A mass mortality event in bats caused by extreme heat: surprising public health challenges.

OBJECTIVES: We examine the public health response to an unprecedented multiple mortality event in bats following an extreme heat event. The main public health risk associated with the event and the environmental clean-up was potential human infection with Australian bat lyssavirus. We also consider the public health implications as we enter an age of climate change, vulnerability and unexpected events. Type of service: The Tropical Public Health Service of Far North Queensland worked collaboratively with the local council to coordinate a practical public health and health protection response to a mass mortality event in bats in late 2018. METHODS: A coordinated response was instigated to remove thousands of decaying bat corpses from residential areas. This occurred alongside a health education campaign advising the public to avoid handling bats. RESULTS: The combined efforts were successful; those requiring vaccination and post-exposure prophylaxis were treated appropriately and owing to a successful campaign, exposures were minimised. However, significant issues with misinformation and social media messaging were noted, alongside amateur bat carers handling sick and injured bats inappropriately, compounding the challenge for public health services. This mass mortality event has implications regarding the preparation for and management of other unexpected public health crises related to climate change. LESSONS LEARNT: It is vital that areas populated with bats be prepared for extreme heat events (EHEs). Public health units need to be prepared for the unexpected events of climate change, advocate for a 'one health' approach to public health, and work with local and national governments to become 'climate ready'.

A systematic review and meta-analysis of published research data on COVID-19 infection fatality rates.

An important unknown during the coronavirus disease-2019 (COVID-19) pandemic has been the infection fatality rate (IFR). This differs from the case fatality rate (CFR) as an estimate of the number of deaths and as a proportion of the total number of cases, including those who are mild and asymptomatic. While the CFR is extremely valuable for experts, IFR is increasingly being called for by policy makers and the lay public as an estimate of the overall mortality from COVID-19. METHODS: Pubmed, Medline, SSRN, and Medrxiv were searched using a set of terms and Boolean operators on 25/04/2020 and re-searched on 14/05/2020, 21/05/2020 and 16/06/2020. Articles were screened for inclusion by both authors. Meta-analysis was performed in Stata 15.1 by using the metan command, based on IFR and confidence intervals extracted from each study. Google/Google Scholar was used to assess the grey literature relating to government reports. RESULTS: After exclusions, there were 24 estimates of IFR included in the final meta-analysis, from a wide range of countries, published between February and June 2020. The meta-analysis demonstrated a point estimate of IFR of 0.68% (0.53%-0.82%) with high heterogeneity (p < 0.001). CONCLUSION: Based on a systematic review and meta-analysis of published evidence on COVID-19 until July 2020, the IFR of the disease across populations is 0.68% (0.53%-0.82%). However, due to very high heterogeneity in the meta-analysis, it is difficult to know if this represents a completely unbiased point estimate. It is likely that, due to age and perhaps underlying comorbidities in the population, different places will experience different IFRs due to the disease. Given issues with mortality recording, it is also likely that this represents an underestimate of the true IFR figure. More research looking at age-stratified IFR is urgently needed to inform policymaking on this front.

Primary Prevention of Cardiovascular Disease in Minority Indigenous Populations: A Systematic Review.

INTRODUCTION: Cardiovascular disease (CVD) is the commonest cause of death across the globe; incidence and prevalence rates are increasing. Together, CVD and diabetes mellitus are responsible for a quarter of the health gap observed between Aboriginal Australians and Torres Strait Islanders, and non-Indigenous Australians. Numerous programs have been proposed and implemented to Close the Gap; ideally, these should be evidence-based. OBJECTIVE: The aim of this review is to evaluate primary prevention measures and programs that aim to reduce CVD risk in minority Indigenous populations around the world. METHODS: A search of PubMed, the Cochrane Library and the Elsevier Scopus Database was initially conducted using the terms "cardiovascular disease", "population groups", "primary prevention", "health services, indigenous", "indigenous health", "risk assessment" and "risk management". Results were then assessed per inclusion/exclusion criteria. A second reviewer independently evaluated the publications and review process to ensure agreement. RESULTS: The initial search produced 37 publications; 19 met the inclusion criteria and were incorporated into a comparative table. Most were descriptive, mixed-methods, audit or intervention studies. Heterogeneity of study design prevented statistical analysis. CONCLUSION: Addressing CVD risk in minority Indigenous populations is a multifactorial challenge; there is substantial room for improvement in routine risk assessment and management. Holistic approaches need to embrace local cultural perceptions of health and wellbeing. Validated risk reduction tools, individualised management plans, polypills and computer based decision support tools are promising to improve outcomes for those at risk.

Safety and tolerability of experimental hookworm infection in humans with metabolic disease: study protocol for a phase 1b randomised controlled clinical trial.

BACKGROUND: Abdominal obesity and presence of the metabolic syndrome (MetS) significantly increase the risk of developing diseases such as Type 2 diabetes mellitus (T2DM) with escalating emergence of MetS and T2DM constituting a significant public health crisis worldwide. Lower prevalence of inflammatory and metabolic diseases such as T2DM in countries with higher incidences of helminth infections suggested a potential role for these parasites in the prevention and management of certain diseases. Recent studies confirmed the potential protective nature of helminth infection against MetS and T2DM via immunomodulation or, potentially, alteration of the intestinal microbiota. This Phase 1b safety and tolerability trial aims to assess the effect of inoculation with helminths on physical and metabolic parameters, immune responses, and the microbiome in otherwise healthy women and men. METHODS: Participants eligible for inclusion are adults aged 18-50 with central obesity and a minimum of one additional feature of MetS recruited from the local community with a recruitment target of 54. In a randomised, double-blind, placebo-controlled design, three groups will receive either 20 or 40 stage three larvae of the human hookworm Necator americanus or a placebo. Eligible participants will provide blood and faecal samples at their baseline and 6-monthly assessment visits for a total of 24 months with an optional extension to 36 months. During each scheduled visit, participants will also undergo a full physical examination and complete diet (PREDIMED), physical activity, and patient health (PHQ-9) questionnaires. Outcome measurements include tolerability and safety of infection with Necator americanus, changes in metabolic and immunological parameters, and changes in the composition of the faecal microbiome. DISCUSSION: Rising cost of healthcare associated with obesity-induced metabolic diseases urgently calls for new approaches in disease prevention. Findings from this trial will provide valuable information regarding the potential mechanisms by which hookworms, potentially via alterations in the microbiota, may positively influence metabolic health. TRIAL REGISTRATION: The protocol was registered on ANZCTR.org.au on 05 June 2017 with identifier ACTRN12617000818336. Alternatively, a Google search using the above trial registration number will yield a direct link to the trial protocol within the ANZCTR website.

Healthy Choice Rewards: A Feasibility Trial of Incentives to Influence Consumer Food Choices in a Remote Australian Aboriginal Community.

Poor diet including inadequate fruit and vegetable consumption is a major contributor to the global burden of disease. Aboriginal and Torres Strait Islander Australians experience a disproportionate level of preventable chronic disease and successful strategies to support Aboriginal and Torres Strait Islander people living in remote areas to consume more fruit and vegetables can help address health disadvantage. Healthy Choice Rewards was a mixed methods study to investigate the feasibility of a monetary incentive: store vouchers, to promote fruit and vegetable purchasing in a remote Australian Aboriginal community. Multiple challenges were identified in implementation, including limited nutrition workforce. Challenges related to the community store included frequent store closures and amended trading times, staffing issues and poor infrastructure to support fruit and vegetable promotion. No statistically significant increases in fruit or vegetable purchases were observed in the short time frame of this study. Despite this, community members reported high acceptability of the program, especially for women with children. Optimal implementation including, sufficient time and funding resources, with consideration of the most vulnerable could go some way to addressing inequities in food affordability for remote community residents.