Background: Liver disease and hepatocellular carcinoma (HCC) are important contributors to the mortality gap between Indigenous and non-Indigenous Australians. However, there is a lack of population based high quality data assessing the differences in HCC epidemiology and outcomes according to Indigenous status. The aim of this study was therefore to perform a large epidemiological study of HCC investigating differences between Indigenous and non-Indigenous Australians with HCC.Methods: Study design was a retrospective cohort study. Data linkage methodology was used to link data from cancer registries with hospital separation summaries across three Australian jurisdictions during 20 0 0-2017. Cumulative survival (Kaplan-Meier) and the differences in survival (Multivariable Coxregression) by Indigenous status were assessed.Findings: A total of 229 Indigenous and 3587 non-Indigenous HCC cases were included in the analyses. Significant epidemiological differences identified for Indigenous HCC cases included younger age at onset, higher proportion of females, higher rurality, lower socioeconomic status, and higher comorbidity burden (all p < 0.001). The distribution of cofactors was also significantly different for Indigenous Australians including higher prevalence of alcohol misuse, hepatitis B, and diabetes and more frequent presence of multiple HCC cofactors (all p < 0.001). Indigenous Australians received curative HCC therapies less frequently (6.6% vs. 14.5%, p < 0.001) and had poorer 5-year survival (10.0% vs. 17.3%, p < 0.001; unadjusted hazard ratio (HR) = 1.42 96%CI 1.21-1.65) compared to non-Indigenous Australians. The strength of the association between indigenous status and survival was weaker and statistically non-significant after adjusting for rurality, comorbidity burden and lack of curative therapy (adjusted-HR = 1.20 95%CI 0.97-1.47) Interpretation: Such data provide a call to action to help design and implement health literacy, liver management and HCC surveillance programs for Indigenous people to help close the liver cancer mortality gap.

The evolution of our four patients seems to be in favor of treatment with an opioid for severe chronic nonmalignant pain in certain pediatric patients, in the context of prescribing in a multidisciplinary pain clinic with a multisystem approach to pain management although more data are needed to know if such therapy is safe and beneficial on a longer-term basis.

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Nothing to declare.Author contribution: Kee Fong Loo contributed to the data collection and analysis, manuscript writing, and review. Richard J Woodman contributed to the data analysis and manuscript review. Damjana Bogatic contributed to the data collection and manuscript review. Kate Muller contributed to the manuscript review. Vidyaleha Chandran contributed to the data collection and manuscript review. Mohamed Asif Chinnaratha contributed to the manuscript review. John Bate contributed to the manuscript review. Kirsty Campbell contributed to the data collection and manuscript review. Matthew Maddison contributed to the data collection and manuscript review. Sumudu Narayana contributed to the ethics submission and manuscript review. Hien Le contributed to the manuscript review. David Pryor contributed to the manuscript review. Alan Wigg contributed to the study design, manuscript writing, and review.

Australia and New Zealand have the highest incidence of all sun-related skin cancers in the world. 1,2,3 This incidence increases with proximity to the equator, leaving residents of Darwin at high risk. 4,5 UV radiation remains one of the strongest modifiable risk factors associated with skin cancers, as such, campaigns promoting sun protection have been widely adopted. 3 Despite this, a previous survey conducted by Whiteman et al. in 1994 found further education is still required among the fair-skinned population in the Northern Territory (NT). 6Darwin has a predominantly Caucasian population, with 14% identifying as non-Caucasian and 8.7% identifying as Aboriginal and/ or Torres Strait Islander (ATSI). 7 We conducted a study to determine if changes in sun protection practices have occurred over the past 22 years in a predominantly fairskinned population exposed to high levels of ultra-violet radiation.This study was designed to replicate one conducted by Whiteman and colleagues and investigate changes in sun protection practices in Darwin. Once ethics approval was obtained, a cross-sectional survey of people attending two weekend markets in Darwin was undertaken. Each market occupied an outdoor site and was made up of stalls selling food, produce and locally made crafts. Seating was available near food stalls with shade offered by outdoor umbrellas and under the cover of storefronts and trees.Interviews for the survey were conducted between August and September 2016 during three weekends of the 'dry season' .The average UV index during the opening hours of the markets ranged between 4 to 7.3, which is considered moderate to high. Periods of extremely high UV index (>11) were also recorded on these weekends. 8 A stall at each market was designated at random as the starting place and attendees were approached at random by one of two interviewees, as per Whiteman et al. 's original study. Participants were excluded if they did not speak English or were under the age of 18 and did not have a consenting adult present. People of all racial groups were included, but data pertaining ATSI participants were not analysed in this study.Demographic information obtained included age, sex, place of birth, ethnicity, Fitzpatrick skin type, level of education, history of skin cancer and duration in Darwin. Sun protection measures were determined by clothing worn, use of sunscreen, sunglasses and choice of head covering.A total of 137 market attendees were included in the study between August and September 2016. Median age was 34 years (range 1 to 81) and 60 (44%) participants were male. A total of 96 (70%) were residents of the Northern Territory (NT), of which 50 (37%) were long-term (more than 5 years), 26 (21%) were medium-term (between one to five years) and 20 (26%) were short-term residents (less than one year). While 75% were born in Australia, only 16 (12%) participants were born in the Northern Territory. Of those sampled, more than 70% were Caucasian. Fitzpatrick skin type was recorded in 131 participants; 23 were rec...