A narrative systematic review of associations and temporality between use of methamphetamine, ecstasy/MDMA, or cocaine with anxiety or depressive symptoms.

OBJECTIVE: Anxiety and depression are prevalent mental health problems in people who use illicit stimulants. Improved understanding of the temporal relationship between methamphetamine, ecstasy/MDMA, or cocaine use with anxiety or depression informs public health interventions and treatment options for those experiencing this co-occurrence. This narrative systematic review sought to examine associations and temporality between the use of methamphetamine, ecstasy/MDMA, or cocaine, with anxiety or depressive symptoms. Method Systematic searches of 4 electronic databases were conducted up to August 2023. Study eligibility included the measurement of anxiety and/or depressive symptoms, and frequency of illicit stimulant use (methamphetamine, cocaine, or ecstasy/MDMA) at two separate time points, with data analysis of the association between these variables. The Joanna Briggs Critical Appraisal Checklist was utilised to assess quality. Data was extracted, and a narrative synthesis incorporating an eight-criteria framework to assess associations was conducted. Results 4432 studies were screened for eligibility; 11 studies (3 RCTs and 8 prospective cohort studies) were included. Evidence for an association between depressive symptoms and methamphetamine use was demonstrated in six studies, with temporal evidence in three studies supporting methamphetamine use preceding depressive symptoms. Three studies reported an association between cocaine use and depressive symptoms. Evidence for associations with any of the illicit stimulants and anxiety symptoms was lacking. CONCLUSIONS: There was some evidence to support a case for temporality, particularly for methamphetamine use and depressive symptoms. Investing in longitudinal studies is pivotal to understanding the dynamic and reciprocal relationship between illicit stimulant use and anxiety or depressive symptoms. A limitation of the study was the variation in the measurement and analysis of outcomes.

The prevalence of drug driving and being caught for a drug driving offense among community-recruited people who use methamphetamine in metropolitan and rural Victoria, Australia.

OBJECTIVE: To examine the prevalence, frequency and characteristics of drug driving and being caught for a drug driving offense and their key correlates among people who used methamphetamine in rural and metropolitan areas of Victoria, Australia. METHODS: Cross-sectional analysis of a sample of 744 people who used methamphetamine. Outcomes included self-reported drug driving (driving within three hours of consuming drugs, yes/no) and having been caught for a drug driving offense (yes/no). Sociodemographic (including rurality) and drug use variables were included in multivariable analyses. RESULTS: Of the 511 participants who reported driving in the six months prior to the survey, 407 (80%) reported drug driving (driving within three hours of taking an illicit drug). Most drug drivers (92.6%) reported taking methamphetamine (in combination with other drugs (59.5%) or in isolation (33.2%)) before driving. Most reported drug driving daily (31%) or weekly (25%), with passengers often (31%) or sometimes (28%). Most reported believing their driving was not at all impaired (49%), or only slightly impaired (32%) when preceded by drug taking. Multivariable analysis revealed that drug driving was not associated with rurality, nor with other socio-demographic characteristics. However, participants residing outside metropolitan areas were more likely to report having been caught previously for a drug driving offense (Adjusted odds ratio [aOR] = 1.93, 95% CI = 1.18-3.16). CONCLUSIONS: The majority of people within this cohort of people who used methamphetamine reported drug driving. An enhanced focus on public health campaigns and strategies to prevent drug driving is needed.

Should I stay or should I go? Observation post-vaccination during the COVID-19 pandemic and the law of unintended consequences.

BACKGROUND: Standard practice after all vaccinations in Australia is to observe patients for 15min. During the coronavirus disease 2019 (COVID-19) pandemic, could the risk of contracting and dying from COVID-19 acquired in the waiting room be greater than the risk of dying from post-vaccine anaphylaxis when leaving immediately? METHODS: The risks are modelled for a patient aged 70+years attending for annual influenza vaccination in a typical Australian general practice clinic. The risk of death from anaphylaxis is estimated based on known rates of anaphylaxis shortly after influenza vaccination. The risk of acquiring COVID-19 during a 15-min wait and then dying from that infection is estimated using the COVID-19 Aerosol Transmission Estimator and COVID-19 Risk Calculator. RESULTS: Other than at times of extremely low COVID-19 prevalence, the risk of death from anaphylaxis for a patient aged 70+years leaving immediately after influenza vaccine is less than the risk of death from COVID-19 acquired via aerosol transmission during a 15-min wait. The risk of death from COVID-19 is greatest for the unimmunised and when masks are not worn. CONCLUSIONS: A more nuanced approach to advice post-vaccination is recommended that considers current COVID-19 prevalence and virulence, the characteristics of the waiting room, the risk of anaphylaxis, and the patient's susceptibility to death from COVID-19. There are many circumstances where it would be safer for a patient to leave immediately after vaccination.

Level and correlates of social support in a community-based sample of Australians who primarily smoke methamphetamine.

Little is known about the level and correlates of social support amongst people who use methamphetamine. We aimed to describe, and determine characteristics associated with, social support amongst a community-recruited cohort of Australians who primarily smoked methamphetamine. A cross-sectional study was conducted with data from the Victorian Methamphetamine Cohort Study (VMAX). Adults (aged ≥18 years) who used methamphetamine were recruited from June 2016 to March 2020 across metropolitan and non-metropolitan areas using convenience, snowball, and respondent-driven sampling. Social support was measured using the seven-item Enhancing Recovery In Coronary Heart Disease (ENRICHD) Social Support Inventory (ESSI). Characteristics independently associated with ESSI quartiles were assessed via multivariable partial proportional odds regression. Overall, 718 participants were included for complete-case analysis. Their mean (standard deviation [SD]) age was 34.7 (9.7) years and 62% were male. The mean (SD) and median (lower quartile-upper quartile) ESSI scores were 22.6 (7.6) and 24 (16-29), respectively, on a scale of 8 to 34 where higher scores denote better self-perceived social support. Characteristics independently associated with lower ESSI included past-year homelessness (adjusted odds ratio [aOR] = 0.49, 95% confidence interval [CI] = 0.36-0.66), moderate/severe depression (aOR = 0.60, 95% CI = 0.42-0.86), increasing age relative to <30 years (aOR[30-39] = 0.61, 95% CI = 0.41-0.91; aOR[≥40] = 0.56, 95% CI = 0.35-0.91) and greater than fortnightly methamphetamine use (aOR = 0.69, 95% CI = 0.52-0.91). Characteristics independently associated with higher ESSI were employment (aOR = 1.51, 95% CI = 1.06-2.14) and female gender (aOR = 1.39, 95% CI = 1.00-1.92). Social support services for people who use methamphetamine could be targeted and tailored to subgroups defined by correlates of social support, such as those who experience homelessness, depression or unemployment.

A critical review of definitions of rural areas in Indonesia and implications for health workforce policy and research.

BACKGROUND: Choosing the appropriate definition of rural area is critical to ensuring health resources are carefully targeted to support the communities needing them most. This study aimed at reviewing various definitions and demonstrating how the application of different rural area definitions implies geographic doctor distribution to inform the development of a more fit-for-purpose rural area definition for health workforce research and policies. METHODS: We reviewed policy documents and literature to identify the rural area definitions in Indonesian health research and policies. First, we used the health policy triangle to critically summarize the contexts, contents, actors and process of developing the rural area definitions. Then, we compared each definition's strengths and weaknesses according to the norms of appropriate rural area definitions (i.e. explicit, meaningful, replicable, quantifiable and objective, derived from high-quality data and not frequently changed; had on-the-ground validity and clear boundaries). Finally, we validated the application of each definition to describe geographic distribution of doctors by estimating doctor-to-population ratios and the Theil-L decomposition indices using each definition as the unit of analysis. RESULTS: Three definitions were identified, all applied at different levels of geographic areas: "urban/rural" villages (Central Bureau of Statistics [CBS] definition), "remote/non-remote" health facilities (Ministry of Health [MoH] definition) and "less/more developed" districts (presidential/regulated definition). The CBS and presidential definitions are objective and derived from nationwide standardized calculations on high-quality data, whereas the MoH definition is more subjective, as it allows local government to self-nominate the facilities to be classified as remote. The CBS and presidential definition criteria considered key population determinants for doctor availability, such as population density and economic capacity, as well as geographic accessibility. Analysis of national doctor data showed that remote, less developed and rural areas (according to the respective definitions) had lower doctor-to-population ratios than their counterparts. In all definitions, the Theil-L-within ranged from 76 to 98%, indicating that inequality of doctor density between these districts was attributed mainly to within-group rather than between-group differences. Between 2011 and 2018, Theil-L-within decreased when calculated using the MoH and presidential definitions, but increased when the CBS definition was used. CONCLUSION: Comparing the content of off-the-shelf rural area definitions critically and how the distribution of health resource differs when analysed using different definitions is invaluable to inform the development of fit-for-purpose rural area definitions for future health policy.

Long-term outcomes of hospital survivors following an ICU stay: A multi-centre retrospective cohort study.

BACKGROUND: The focus of much Intensive Care research has been on short-term survival, which has demonstrated clear improvements over time. Less work has investigated long-term survival, and its correlates. This study describes long-term survival and identifies factors associated with time to death, in patients who initially survived an Intensive Care admission in Victoria, Australia. METHODS: We conducted a retrospective cohort study of adult patients discharged alive from hospital following admission to all Intensive Care Units (ICUs) in the state of Victoria, Australia between July 2007 and June 2018. Using the Victorian Death Registry, we determined survival of patients beyond hospital discharge. Comparisons between age matched cohorts of the general population were made. Cox regression was employed to investigate factors associated with long-term survival. RESULTS: A total of 130,775 patients from 23 ICUs were included (median follow-up 3.6 years post-discharge). At 1-year post-discharge, survival was 90% compared to the age-matched cohort of 98%. All sub-groups had worse long-term survival than their age-matched general population cohort, apart from elderly patients admitted following cardiac surgery who had better or equal survival. Multiple demographic, socio-economic, diagnostic, acute and chronic illness factors were associated with long-term survival. CONCLUSIONS: Australian patients admitted to ICU who survive to discharge have worse long-term survival than the general population, except for the elderly admitted to ICU following cardiac surgery. These findings may assist during goal-of-care discussions with patients during an ICU admission.

Mandatory bulk billing policies may have differential rural effects: an exploration of Australian data.

INTRODUCTION: Over the course of the COVID-19 pandemic, Australian general practices have rapidly pivoted to telephone and video call consultations for infection control and prevention. Initially these telehealth consultations were required to be bulk billed (doctors could only charge fees equivalent to the national Medicare Benefits Schedule (MBS)). The potential impact of this policy on general practices − and particularly rural general practices - has been difficult to assess because there is limited published data about which practices are less likely to bulk bill and therefore more impacted by mandatory bulk billing policies. There was concern that bulk billing only policies could have a broader impact on rural practices, which may rely on mixed or private billing for viability in small communities where complex care is often needed. This study aimed to understand the patterns of bulk billing nationally and explore the characteristics of practices more or less likely to bulk bill patients, to identify the potential impact of a rapid shift to bulk billing only policies. METHODS: General practice bulk billing patterns were described using aggregate statistics from Australian Department of Health public MBS datasets. Bulk billing rates were explored over time by rurality, and state or territory. Next, questions about bulk billing were included in a cross-sectional survey of practices conducted in 2019 by General Practice Supervisors Australia (GPSA). Practice bulk billing patterns were explored by rurality, state or territory and practice size at univariate level before a multivariate logistic regression model was done, including the statistically significant variables. RESULTS: Nationally, bulk billing rates for general practice non-referred attendances increased over 2012-2019 from 82% to 86% but declined slightly in Modified Monash Model (MMM)2−7 (rural areas) at the end of this period. Further, bulk billing rates varied by rurality, and were highest in very remote (MMM7) (89-91%) and metropolitan areas (MMM1) (83-87%) and lowest in regional centres (MMM2) (76-82%) over this period. The results from the GPSA survey concurred with national data, showing that the proportion of practices bulk billing all patients was highest in metropolitan locations (28%) and lowest in regional centres and large rural towns (MMM2−3) (16%). Smaller practices (five or fewer general practitioners) were more likely to bulk bill all patients than were larger ones (six or more general practitioners). Multivariate modelling showed that bulk billing all patients was statistically significantly (p<0.05) less likely for larger practices compared with smaller ones, and for rural practices (MMM2−7) compared with those in metropolitan areas. CONCLUSION: Mandatory bulk billing policies should accommodate the fact that bulk billing varies by context, including rurality and the size of a practice, and has been decreasing in rural areas over recent years. Rapidly pivoting to bulk billing only service models may put pressure on rural and large practices unless they have time to adjust their business models and have ways to offset the loss of billings. Policies that allow for a range of billing arrangements may be important for practices to fit billings to their local context of care, including in rural settings, thereby supporting business viability and the availability of sustainable primary care services.

Long term survival following a medical emergency team call at an Australian regional hospital.

Objective: To investigate the long term survival of medical emergency team (MET) patients at an Australian regional hospital and describe associated patient and MET call characteristics. Design: Retrospective cohort study. Data linkage to the statewide death registry was performed to allow for long term survival analysis, including multivariable Cox proportional hazards regression and production of Kaplan-Meier survival curves. Setting: A large Australian regional hospital. Participants: Adult patients who received a MET call from 1 July 2012 to 3 March 2020. Main outcome measures: Survival to 30, 90 and 180 days; one year; and 5-years after index MET call. Results: The study included 6499 eligible patients. The cohort median age was 71 years, and 52.4% of the patients were female. Surgical (39.6%) and medical (36.9%) patients comprised most of the cohort. Thirty-day survival was 86.5% one-year survival was 66.1%. Among patients aged < 75 years, factors independently associated with significantly higher long term mortality included age (hazard ratio [HR], 3.26 [95% CI, 2.63-4.06]; for patients aged 65-74 v 18-54 years), male sex (HR, 0.71 [95% CI, 0.61-0.83]; for females) and pre-existing limitation of medical therapy (HR, 2.76; 95% CI, 2.28-3.35). Among patients aged ≥ 75 years, factors independently associated with significantly higher long term mortality included age (HR, 1.46 [95% CI, 1.29-1.65]; for patients aged ≥ 85 years), male sex (HR, 0.74 [95% CI, 0.66-0.83]; for females), and altered MET criteria (HR, 1.33; 95% CI, 1.03-1.71). Conclusions: Long term survival probabilities of MET call patients are affected by factors including age, sex, and limitation of medical therapy status. These data may be useful for clinicians conducting end-of-life discussions with patients.

Correlates of anxiety and depression in a community cohort of people who smoke methamphetamine.

OBJECTIVE: Anxiety and depression are the most common mental health disorders experienced by Australians. These disorders are commonly found in people who use methamphetamine; however, much of this research has involved participants recruited from treatment settings who inject methamphetamine. We therefore explored (1) the prevalence of moderate to severe anxiety and depression in a community-recruited cohort who smoked methamphetamine and (2) examined potential factors associated with moderate to severe anxiety or depression in this cohort. METHOD: Data were derived from baseline surveys of 725 participants of the prospective 'VMAX' study, recruited from metropolitan and non-metropolitan areas of Victoria, Australia, via snowball and respondent-driven sampling. Anxiety and depression were measured using the Generalized Anxiety Disorder-7 and the Patient Health Questionnaire-9 instruments. Independent associations between moderate to severe scores on these measures and demographic, socio-economic, substance use and other health and social characteristics were examined using multivariable logistic regression. RESULTS: More than half (60%) of the participants were classified as experiencing moderate to severe anxiety and/or depression. In the multivariable models, having poor/very poor self-rated health, methamphetamine dependence and being unemployed were associated with higher odds of experiencing both moderate to severe depression and moderate to severe anxiety. Living in a large rural town, identifying as Aboriginal and Torres Strait Islander and smoking methamphetamine were associated with lower odds of experiencing moderate to severe depression. Being female was associated with higher odds of experiencing moderate to severe anxiety. CONCLUSION: The high rates of anxiety and/or depression found in the VMAX cohort were associated with demographic, socio-economic, substance use and other health and social factors. The prevalence of moderate to severe anxiety is a novel finding that warrants further study. Further work is needed to determine how anxiety and depression change over time among people who smoke methamphetamine, to help identify key intervention points.

Functional outcomes following an in-hospital cardiac arrest: A retrospective cohort study.

BACKGROUND/PURPOSE: Whilst much is known about the survival outcomes of patients that suffer an in-hospital cardiac arrest (IHCA) in Australia very little is known about the functional outcomes of survivors. This study aimed to describe the functional outcomes of a cohort of patients that suffered an in-hospital cardiac arrest (IHCA) and survived to hospital discharge in a regional Australian hospital. METHODS: This is a single-centre retrospective observational cohort study conducted in a regional Australian hospital. All adult patients that had an IHCA in the study hospital between 1 Jan 2017 and 31 Dec 2019 and survived to hospital discharge were included in the study. Functional outcomes were reported using the Modified Rankin Scale (mRS), a six-point scale for which increasing scores represent increasing disability. Scores were assigned through a retrospective review of medical notes. RESULTS: Overall, 102 adult patients had an IHCA during the study period, of whom 50 survived to hospital discharge. The median age of survivors was 68 years, and a third had a shockable initial arrest rhythm. Of survivors, 47 were able to be assigned both mRS scores. At discharge, 81% of patients achieved a favourable functional outcome (mRS 0-3 or equivalent function at discharge equal to admission). CONCLUSIONS: Most survivors to hospital discharge following an IHCA have a favourable functional outcome and are discharged home. Although these results are promising, larger studies across multiple hospitals are required to further inform what is known about functional outcomes in Australian IHCA survivors.

The impact of telehealth on patient attendance and revenue within an Aboriginal Community Controlled Health Organisation during COVID-19.

BACKGROUND AND OBJECTIVES: Aboriginal Community Controlled Health Organisations (ACCHOs) provide culturally appropriate medical services to Aboriginal and/or Torres Strait Islander people. The aim of this study was to examine the impact of telehealth on patient attendance and revenue within an ACCHO during COVID-19. METHOD: This is a time-series study of general practitioner attendances at a regional Victorian ACCHO in two periods: March-June 2019 (pre-COVID-19) and March-June 2020 (during COVID-19). RESULTS: After adjusting for the number of available appointments, there was a 27% increased rate of attendances per appointment slot during the COVID-19 period when compared with the pre-COVID-19 period, and a 59% increase in Medicare Benefits Schedule items claimed during the COVID-19 period, compared with the pre-COVID-19 period. DISCUSSION: The findings indicate that the provision of services via telehealth increased the number of people able to access the medical clinic, and that this had a positive financial impact for the organisation.

Random case analysis in general practice clinical team meetings.

BACKGROUND: The Medical Board of Australia intends to mandate that at least 25% of continuing professional development (CPD) is focused on performance review. OBJECTIVE: The aim of this article is to describe how random case analysis (RCA) can be used for performance review in general practice clinical team meetings, and outline its benefits and challenges. DISCUSSION: RCA is a powerful learning method for CPD. Involving peers in case review allows practice quality improvement and safety issues to be explored. Planning is required to overcome logistic and legal barriers and to ensure accreditation of the activity by The Royal Australian College of General Practitioners. Vital to the success of RCA is a supportive educational environment and the provision of learner-centred and specific feedback.

Exploring attributes of high-quality clinical supervision in general practice through interviews with peer-recognised GP supervisors.

BACKGROUND: Clinical supervision in general practice is critical for enabling registrars (GP trainees) to provide safe medical care, develop skills and enjoy primary care careers. However, this largely depends on the quality of supervision provided. There has been limited research describing what encompasses quality within GP clinical supervision, making it difficult to promote best practice. This study aimed to explore the attributes of high-quality clinical supervision for GP registrars. METHODS: In 2019-20, 22 semi-structured interviews were conducted with GP supervisors who were peer-nominated as best practice supervisors, by Regional GP Training Organisations and GP Colleges in Australia. Purposeful sampling sought respondents with diverse characteristics including gender and career stage, practice size, state/territory and rurality. Interviews were conducted by video-consultation and recorded. De-identified transcripts were independently coded using iterative, inductive thematic analyses to derive themes that reflected quality in GP supervision. RESULTS: Seven themes emerged. Participants understood the meaning of quality supervision based on their experience of being supervised when they were a registrar, and from reflecting and learning from other supervisors and their own supervision experiences. Quality was reflected by actively structuring GP placements to optimise all possible learning opportunities, building a secure and caring relationship with registrars as the basis for handling challenging situations such as registrar mistakes. Quality also encompassed sustaining and enhancing registrar learning by drawing on the input of the whole practice team who had different skills and supervision approaches. Strong learner-centred approaches were used, where supervisors adjusted support and intervention in real-time, as registrar competence emerged in different areas. Quality also involved building the registrar's professional identity and capabilities for safe and independent decision-making and encouraging registrars to reflect on situations before giving quality feedback, to drive learning. CONCLUSIONS: This study, although exploratory, provides a foundation for understanding the quality of clinical supervision in general practice, from the perspective of peer-recognised GP supervisors. Understanding and adopting quality within GP supervision may be improved by GPs sharing exemplars of best practice and having opportunities for professional reflection. The findings could be used as a point of reference for devising GP supervisor curriculum, resources and professional development activities.

Factors Associated With Working in Remote Indonesia: A National Cross-Sectional Study of Early-Career Doctors.

Background: Doctor shortages in remote areas of Indonesia are amongst challenges to provide equitable healthcare access. Understanding factors associated with doctors' work location is essential to overcome geographic maldistribution. Focused analyses of doctors' early-career years can provide evidence to strengthen home-grown remote workforce development. Method: This is a cross-sectional study of early-career (post-internship years 1-5) Indonesian doctors, involving an online self-administered survey on demographic characteristics, and; locations of upbringing, medical clerkship (placement during medical school), internship, and current work. Multivariate logistic regression was used to test factors associated with current work in remote districts. Results: Of 3,176 doctors actively working as clinicians, 8.9% were practicing in remote districts. Compared with their non-remote counterparts, doctors working in remote districts were more likely to be male (OR 1.5,CI 1.1-2.1) or unmarried (OR 1.9,CI 1.3-3.0), have spent more than half of their childhood in a remote district (OR 19.9,CI 12.3-32.3), have completed a remote clerkship (OR 2.2,CI 1.1-4.4) or internship (OR 2.0,CI 1.3-3.0), currently participate in rural incentive programs (OR 18.6,CI 12.8-26.8) or have previously participated in these (OR 2.0,CI 1.3-3.0), be a government employee (OR 3.2,CI 2.1-4.9), or have worked rurally or remotely post-internship but prior to current position (OR 1.9,CI 1.2-3.0). Conclusion: Our results indicate that building the Indonesian medical workforce in remote regions could be facilitated by investing in strategies to select medical students with a remote background, delivering more remote clerkships during the medical course, deploying more doctors in remote internships and providing financial incentives. Additional considerations include expanding government employment opportunities in rural areas to achieve a more equitable geographic distribution of doctors in Indonesia.

A Framework to Guide the Implementation of Best Practice Clinical Learning Environments in Community General Practice: Australia.

Clinical education/training is increasingly being expanded to community general practice settings (primary care clinics led by doctors). This plays an important role in developing a skilled "primary-care ready" workforce. However, there is limited information to guide the implementation of high-quality learning environments suitable for the range of general practices and clinical learners they oversee. We aimed to develop a consensus-based framework to address this. A co-design participatory action research method involved working with stakeholders to agree a project plan, collect and interpret data and endorse a final framework. As a starting point, an initial draft framework was adapted from an existing framework, the Best Practice Clinical Learning Environment (BPCLE) Framework. We gathered feedback about this from a national GP Supervisor Liaison Officer Network (SLON) (experienced GP clinical supervisors) during a 90-minute face-to-face focus group. They rated their agreement with the relevance of objectives and elements, advising on clear terminology and rationale for including/excluding various components. The resulting framework was refined and re-tested with the SLON and wider GP educational stakeholders until a final graphically designed version was endorsed. The resulting "GP Clinical Learning Environment" (GPCLE) Framework is applicable for planning and benchmarking best practice learning environments in general practice.

Parent and child co-resident status among an Australian community-based sample of methamphetamine smokers.

INTRODUCTION: Children in families where there is substance misuse are at high risk of being removed from their parents' care. This study describes the characteristics of a community sample of parents who primarily smoke methamphetamine and their child or children's residential status. DESIGN AND METHODS: Baseline data from a prospective study of methamphetamine smokers ('VMAX'). Participants were recruited via convenience, respondent-driven and snowball sampling. Univariable and multivariable logistic regression analyses were used to estimate associations between parental status; fathers' or mothers' socio-demographic, psychosocial, mental health, alcohol, methamphetamine use dependence, alcohol use and child or children's co-residential status. RESULTS: Of the 744 participants, 394 (53%) reported being parents; 76% (88% of fathers, 57% of mothers) reported no co-resident children. Compared to parents without co-resident children, parents with co-resident children were more likely to have a higher income. Fathers with co-resident children were more likely to be partnered and not to have experienced violence in the previous 6 months. Mothers with co-resident children were less likely to have been homeless recently or to have accessed treatment for methamphetamine use. DISCUSSION AND CONCLUSIONS: The prevalence of non-co-resident children was much higher than previously reported in studies of parents who use methamphetamine; irrespective of whether in or out of treatment. There is a need for accessible support and services for parents who use methamphetamine; irrespective of their child or children's co-residency status. Research is needed to determine the longitudinal impact of methamphetamine use on parents' and children's wellbeing and to identify how parents with co-resident children (particularly mothers) can be supported.

Stress urinary incontinence in the mesh complication era: current Australian trends.

OBJECTIVES: To examine available data relating to the surgical management of stress urinary incontinence (SUI) in Australia before, during and after a well-publicized Senate Inquiry into transvaginal mesh use and to consider outcomes in the context of global guideline changes. PATIENTS AND METHODS: The annual number of surgical procedures for the management of SUI by procedure type and age group for the years 2008/2009-2017/2018 was obtained from the Australian Government Department of Human Services database using Medicare Benefits Schedule item numbers. The data extracted were limited to women aged 25 years and older. These data were used to calculate age-specific and age-standardized rates, so as to accurately analyse trends in the usage of different procedures. Hospital Episode Statistics for mid-urethral sling (MUS) insertions were obtained for England's National Health Service from the Health and Social Care Information Centre for the years 2008/2009-2016/2017. These data were also used to calculate annual age-standardized rates for comparison purposes. RESULTS: Rates declined for most SUI procedures over time (MUS, colposuspension, fascial slings) except for urethral bulking agents. The absolute number of MUSs implanted in 2008/2009 was 5729, which decreased to 3127 in the 2017/2018 financial year. Over the decade, the annual rate for MUS implantation per 100 000 population halved from 78 to 36. Over this same period, the rate of usage of bulking agents doubled, although represented a low volume of procedures (overall numbers increased from 304 to 698, representing an increase from four to eight procedures per 100 000 population). The age-specific peak rate for MUS and Burch colposuspension changed over the decade from 55-64 years to 65-74 years, suggesting that women are deferring surgical treatment until later in life. Over the last decade, the total number of surgical procedures performed in Australia to treat SUI has decreased markedly from 6812 to 4279. This represents a decrease in the annual rate per 100 000 population from 93 to 49. CONCLUSIONS: There are clear changes evident for SUI management in the past decade in Australia, including an overall decline in operative numbers, which correlate with international advisory notifications and local investigations. The results of the Australian Senate inquiry, including removal of single-incision mini-slings, greater availability of patient resources, and greater regulation of SUI procedures, will probably have ongoing effects. Surgeons need to ensure that sufficient training and patient education continue in order to maintain appropriate access to treatment of SUI in the future.

Factors associated with increasing rural doctor supply in Asia-Pacific LMICs: a scoping review.

BACKGROUND: More than 60% of the world's rural population live in the Asia-Pacific region. Of these, more than 90% reside in low- and middle-income countries (LMICs). Asia-Pacific LMICs rural populations are more impoverished and have poorer access to medical care, placing them at greater risk of poor health outcomes. Understanding factors associated with doctors working in rural areas is imperative in identifying effective strategies to improve rural medical workforce supply in Asia-Pacific LMICs. METHOD: We performed a scoping review of peer-reviewed and grey literature from Asia-Pacific LMICs (1999 to 2019), searching major online databases and web-based resources. The literature was synthesized based on the World Health Organization Global Policy Recommendation categories for increasing access to rural health workers. RESULT: Seventy-one articles from 12 LMICs were included. Most were about educational factors (82%), followed by personal and professional support (57%), financial incentives (45%), regulatory (20%), and health systems (13%). Rural background showed strong association with both rural preference and actual work in most studies. There was a paucity in literature on the effect of rural pathway in medical education such as rural-oriented curricula, rural clerkships and internship; however, when combined with other educational and regulatory interventions, they were effective. An additional area, atop of the WHO categories was identified, relating to health system factors, such as governance, health service organization and financing. Studies generally were of low quality-frequently overlooking potential confounding variables, such as respondents' demographic characteristics and career stage-and 39% did not clearly define 'rural'. CONCLUSION: This review is consistent with, and extends, most of the existing evidence on effective strategies to recruit and retain rural doctors while specifically informing the range of evidence within the Asia-Pacific LMIC context. Evidence, though confined to 12 countries, is drawn from 20 years' research about a wide range of factors that can be targeted to strengthen strategies to increase rural medical workforce supply in Asia-Pacific LMICs. Multi-faceted approaches were evident, including selecting more students into medical school with a rural background, increasing public-funded universities, in combination with rural-focused education and rural scholarships, workplace and rural living support and ensuring an appropriately financed rural health system. The review identifies the need for more studies in a broader range of Asia-Pacific countries, which expand on all strategy areas, define rural clearly, use multivariate analyses, and test how various strategies relate to doctor's career stages.