Topics

Endocrine system diseases

Diagnosis of autoimmune β-cell disorder before end-stage clinical type 1 diabetes is a key step towards the prevention of this disease

1 Women's and Children's Hospital, Adelaide, SA
2 University of Adelaide, Adelaide, SA
3 Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC

Correspondence: Jennifer.Couper@adelaide.edu.au

Acknowledgements:

We acknowledge the contributions to the manuscript of Megan Penno and the community support and perspective provided by Juvenile Diabetes Research Foundation Australia, the recipient of the Australian Research Council Special Research Initiative in Type 1 Diabetes. Leonard Harrison was supported by a National Health and Medical Research Council Senior Principal Research Fellowship (1080887).

Competing interests:

No relevant disclosures.

1. Haynes A, Bulsara MK, Bower C, et al. Regular peaks and troughs in the Australian incidence of childhood type 1 diabetes mellitus (2000–2011). Diabetologia 2015; 58: 2513–2516.
2. Phelan H, Clapin H, Bruns L, et al. The Australasian Diabetes Data Network: first national audit of children and adolescents with type 1 diabetes. Med J Aust 2017; 206: 121–125. https://www.mja.com.au/journal/2017/206/3/australasian-diabetes-data-network-first-national-audit-children-and-adolescents
3. Ziegler AG, Rewers M, Simell O, et al. Seroconversion to multiple islet autoantibodies and risk of progression to diabetes in children. JAMA 2013; 309: 2473–2479.
4. Raab J, Haupt F, Scholz M, et al. Capillary blood islet autoantibody screening for identifying pre‐type 1 diabetes in the general population: design and initial results of the Fr1da study. BMJ Open 2016; 6: e11144.
5. Insel RA, Dunne JL, Atkinson MA, et al. Staging presymptomatic type 1 diabetes: a scientific statement of JDRF, the Endocrine Society and the American Diabetes Association. Diabetes Care 2015; 38: 1964–1974.
6. Colman PG, McNair P, Margetts H, et al. The Melbourne Pre‐Diabetes Study: prediction of type 1 diabetes mellitus using antibody and metabolic testing. Med J Aust 1998; 169: 81–84.
7. Bonifacio E, Mathieu C, Nepom GT, et al. Rebranding asymptomatic type 1 diabetes: the case for autoimmune beta cell disorder as a pathological and diagnostic entity. Diabetologia 2017; 60: 35–38.
8. Department of Health. Australian National Diabetes Strategy 2016–2020. Canberra: Commonwealth of Australia, 2015. http://www.health.gov.au/internet/main/publishing.nsf/Content/nds-2016-2020 (viewed Jan 2019).
9. King BR, Howard NJ, Verge CF, et al. A diabetes awareness campaign prevents diabetic ketoacidosis in children at their initial presentation with type 1 diabetes. Pediatr Diabetes 2012; 13: 647–651.
10. Duca LM, Wang B, Rewers M, Rewers A. Diabetic ketoacidosis at diagnosis of type 1 diabetes predicts poor long‐term glycemic control. Diabetes Care 2017; 4: 1249–1255.
11. Winkler C, Schober E, Ziegler AG, Holl RW. Markedly reduced rate of diabetic ketoacidosis at onset of type 1 diabetes in relatives screened for islet autoantibodies. Pediatr Diabetes 2012; 13: 308–313.
12. Steck AK, Larsson HE, Liu X, et al. Residual beta‐cell function in diabetes children followed and diagnosed in the TEDDY study compared with community controls. Pediatr Diabetes 2017; 18: 794–802.
13. Gesualdo PD, Bautista KA, Waugh KC, et al. Feasibility of screening for T1D and celiac disease in a pediatric clinic setting. Pediatr Diabetes 2016; 17: 441–448.
14. Smith LB, Liu X, Johnson SB, et al. Family adjustment to diabetes diagnosis in children: can participation in a study on type 1 diabetes genetic risk be helpful? Pediatr Diabetes 2018; 19: 1025–1033.
15. Herold KC, Bundy BN, Long A, et al. An anti‐CD3 antibody, teplizumab, in relatives with type 1 diabetes. N Engl J Med 2019. https://doi.org/10.1056/nejmoa1902226. [Epub ahead of print]
16. Bingley PJ, Bonifacio E, Williams AJ, et al. Prediction of IDDM in the general population: strategies based on combinations of autoantibody markers. Diabetes 1997; 46: 1701–1710.

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Perspectives

Primary prevention implantable cardioverter defibrillators in non‐ischaemic cardiomyopathy: challenging the Australian heart failure guidelines

Dennis H Lau, Jonathan M Kalman and Prashanthan Sanders

Med J Aust 2019; 211 (4): . || doi: 10.5694/mja2.50248
Published online: 19 August 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Cardiovascular diseases

The 2018 Australian guidelines recommendations require further clarification to ensure eligible patients will receive appropriate ICD therapy

The implantable cardioverter defibrillator (ICD) has been shown to be a cost‐effective option for primary prevention of sudden cardiac death (SCD) in patients with heart failure with reduced ejection fraction (HFrEF). However, in the recently published 2018 guidelines for the prevention, detection and management of heart failure in Australia, the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand Heart Failure Guidelines Working Group downgraded the recommendation for primary prevention ICD to decrease mortality in patients with HFrEF and left ventricular ejection fraction (LVEF) 35% or below associated with non‐ischaemic cardiomyopathy (NICM).1,2 In particular, the level of recommendation and quality of evidence for primary prevention ICD was deemed weak and low for NICM versus strong and moderate for ischaemic cardiomyopathy, respectively. The document cited the lack of single randomised controlled trials demonstrating mortality benefits with primary prevention ICD in patients with NICM. It also highlighted recent prospective randomised controlled data of 1116 patients with HFrEF and LVEF 35% or below associated with non‐ischaemic causes from the DANISH trial — a Danish study to assess the efficacy of ICD in patients with non‐ischaemic systolic heart failure on mortality — whereby primary prevention ICD did not reduce mortality compared with usual clinical care over a median follow‐up duration of 67.6 months (interquartile range, 49–85 months).3

1 Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, SA
2 Royal Adelaide Hospital, Adelaide, SA
3 University of Melbourne, Melbourne, VIC
4 Royal Melbourne Hospital, Melbourne, VIC

Correspondence: Prash.Sanders@adelaide.edu.au

Acknowledgements:

Dennis Lau is supported by the Robert J Craig Lectureship from the University of Adelaide. Jonathan Kalman and Prashanthan Sanders are supported by Practitioner Fellowships from the National Health and Medical Research Council. Prashanthan Sanders is supported by the National Heart Foundation of Australia.

Competing interests:

The University of Adelaide reports receiving on behalf of Dennis Lau lecture and/or consulting fees from Abbott, Bayer, Biotronik and Pfizer. Prashanthan Sanders reports having served on the advisory board of Biosense‐Webster, Medtronic, Abbott, Boston Scientific and CathRx. The University of Adelaide reports receiving on behalf of Prashanthan Sanders lecture and/or consulting fees from Biosense‐Webster, Medtronic, Abbott, and Boston Scientific. The University of Adelaide reports receiving on behalf of Prashanthan Sanders research funding from Medtronic, Abbott, Boston Scientific, Biotronik and Liva Nova.

1. Atherton JJ, Sindone A, De Pasquale CG, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of heart failure 2018. Med J Aust 2018; 209: 363–369. https://www.mja.com.au/journal/2018/209/8/national-heart-foundation-australia-and-cardiac-society-australia-and-new-0
2. Atherton JJ, Sindone A, De Pasquale CG, et al; NHFA CSANZ Heart Failure Guidelines Working Group. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: guidelines for the prevention, detection, and management of heart failure in Australia 2018. Heart Lung Circ 2018; 27: 1123–1208.
3. Kober L, Thune JJ, Nielsen JC, et al. Defibrillator implantation in patients with nonischemic systolic heart failure. N Engl J Med 2016; 375: 1221–1230.
4. Bennett M, Parkash R, Nery P, et al. Canadian Cardiovascular Society/Canadian Heart Rhythm Society 2016 implantable cardioverter‐defibrillator guidelines. Can J Cardiol 2017; 33: 174–188.
5. Al‐Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm 2018; 15: e73–e189.
6. Haugaa KH, Tilz R, Boveda S, et al. Implantable cardioverter defibrillator use for primary prevention in ischaemic and non‐ischaemic heart disease‐indications in the post‐DANISH trial era: results of the European Heart Rhythm Association survey. Europace 2017; 19: 660–664.
7. Al‐Khatib SM, Fonarow GC, Joglar JA, et al. Primary prevention implantable cardioverter defibrillators in patients with nonischemic cardiomyopathy: a meta‐analysis. JAMA Cardiol 2017; 2: 685–688.
8. Golwala H, Bajaj NS, Arora G, Arora P. Implantable cardioverter‐defibrillator for nonischemic cardiomyopathy: an updated meta‐analysis. Circulation 2017; 135: 201–203.
9. Luni FK, Singh H, Khan AR, et al. Mortality effect of ICD in primary prevention of nonischemic cardiomyopathy: a meta‐analysis of randomized controlled trials. J Cardiovasc Electrophysiol 2017; 28: 538–543.
10. Shun‐Shin MJ, Zheng SL, Cole GD, et al. Implantable cardioverter defibrillators for primary prevention of death in left ventricular dysfunction with and without ischaemic heart disease: a meta‐analysis of 8567 patients in the 11 trials. Eur Heart J 2017; 38: 1738–1746.
11. Bristow MR, Saxon LA, Boehmer J, et al; Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) Investigators. Cardiac‐resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 2004; 350: 2140–2150.
12. Felker GM, Thompson RE, Hare JM, et al. Underlying causes and long‐term survival in patients with initially unexplained cardiomyopathy. N Engl J Med 2000; 342: 1077–1084.
13. Elming MB, Nielsen JC, Haarbo J, et al. Age and outcomes of primary prevention implantable cardioverter‐defibrillators in patients with nonischemic systolic heart failure. Circulation 2017; 136: 1772–1780.
14. Thavapalachandran S, Leong DP, Stiles MK, et al. Evidence‐based management of heart failure in clinical practice: a review of device‐based therapy use. Intern Med J 2009; 39: 669–675.
15. Munawar DA, Mahajan R, Linz D, et al. Predicted longevity of contemporary cardiac implantable electronic devices: a call for industry‐wide “standardized” reporting. Heart Rhythm 2018; 15: 1756–1763.
16. Pathak RK, Sanders P, Deo R. Primary prevention implantable cardioverter‐defibrillator and opportunities for sudden cardiac death risk assessment in non‐ischaemic cardiomyopathy. Eur Heart J 2018; 39: 2859–2866.

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Perspectives

The future of academic publishing: disruption, opportunity and a new ecosystem

Virginia Barbour

Med J Aust 2019; 211 (4): . || doi: 10.5694/mja2.50265
Published online: 19 August 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Health services administration

Information science

Academic publishing is on an irreversible path to change

It is not a hyperbole to say that the foundations of academic publishing are in a state of large‐scale disruption. That this disruption remains largely under the surface is primarily because the main users of academic research — those who work at universities — rarely suffer the consequences of lack of access due to the substantial payments universities make for subscription journals (about $281 million in total in Australia in 2017).1 Outside of universities, however, gaining online access to published research legally is neither easy nor affordable. Furthermore, as we move towards an interconnected digital future, it is becoming increasingly obvious that a system whose core business model rests on controlling access is an anachronism.

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Queensland University of Technology, Brisbane, QLD

Correspondence: Ginny.Barbour@qut.edu.au

Competing interests:

Virginia Barbour is member of the NHMRC Research Quality Steering Committee and is employed by the Australasian Open Access Strategy Group. She was previously employed by PLOS, was Chair of the Committee on Publication Ethics, and is currently Chair of the DORA international advisory committee and a Plan S ambassador.

1. Parliament of Australia. Australian Government funding arrangements for non‐NHMRC research [website]. Canberra: Commonwealth of Australia, 2018. https://www.aph.gov.au/Parliamentary_Business/Committees/House/Employment_Education_and_Training/FundingResearch/Report (viewed Apr 2019).
2. Budapest Open Access Initiative. Read the Budapest Open Access Initiative [website]. https://www.budapestopenaccessinitiative.org/read (viewed Mar 2019).
3. Australian Public Service Commission. Tackling wicked problems : a public policy perspective [website]. Canberra: Australian Public Service Commission, 2018. https://www.apsc.gov.au/tackling-wicked-problems-public-policy-perspective (viewed Mar 2019).
4. Larivière V, Haustein S, Mongeon P. The oligopoly of academic publishers in the digital era. PLoS ONE 2015; 10: e0127502.
5. SPARC. Big deal cancellation tracking [website]. https://sparcopen.org/our-work/big-deal-cancellation-tracking (viewed Apr 2019).
6. University of California Office of Scholarly Communication. UC and Elsevier — open statement: why UC terminated journal negotiations with Elsevier [website]. UC OSC, 2019. https://osc.universityofcalifornia.edu/open-access-at-uc/publisher-negotiations/uc-and-elsevier (viewed Mar 2019).
7. Confederation of Open Access Repositories. Next generation repositories [website]. COAR, 2017. https://www.coar-repositories.org/activities/advocacy-leadership/working-group-next-generation-repositories (viewed Mar 2019).
8. Baker M. 1,500 scientists lift the lid on reproducibility. Nature 2016; 533: 452–454.
9. Finkel A. To move research from quantity to quality, go beyond good intentions. Nature 2019; 566: 297.
10. National Health and Medical Research Council. Research quality [website]. Canberra: NHMRC. https://nhmrc.gov.au/research-quality (viewed Mar 2019).
11. Council of Australian University Librarians. Fair, affordable and open access to knowledge [website]. Canberra: CAUL, 2017. https://www.caul.edu.au/programs-projects/fair-affordable-open-access-knowledge (viewed Mar 2019).
12. Department of Industry Innovation and Science. Government response: Productivity Commission Inquiry into intellectual property arrangements [website]. Canberra: Department of Industry, 2017. https://www.industry.gov.au/data-and-publications/government-response-productivity-commission-inquiry-into-intellectual-property-arrangements (viewed Mar 2019).

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Perspectives

Advancing women in medical leadership

Helena J Teede

Med J Aust 2019; 211 (9): . || doi: 10.5694/mja2.50287
Published online: 12 August 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Health services administration

Equity underpins workforce diversity, embraces and values differences, harnesses talents and skills, and represents and responds to community needs

Monash Partners Academic Health Sciences Centre, Monash University and Monash Health, Melbourne, VIC

Correspondence: helena.teede@monash.edu

Acknowledgements:

I have held National Health Medical and Research Council fellowship funding throughout my clinical academic career and have been employed and supported through leadership training and career development opportunities by both Monash University and Monash Health. I acknowledge the many women and men who have provided mentorship throughout my career. I thank Heidi Burgmeier for critical input into the manuscript and Anjali Dhulia for her role in the Monash Health Women in Leadership initiatives.

Competing interests:

Helena Teede runs and facilitates Women in Leadership training programs with Monash Health and Monash University with all funds going to the institution.

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6. Weiss A, Lee KC, Tapia V, et al. Equity in surgical leadership for women: more work to do. Am J Surg 2014; 208: 494–498.
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8. Santen RJ, Joham A, Fishbein L, et al. Career advancement: meeting the challenges confronting the next generation of endocrinologists and endocrine researchers. J Clin Endocrinol Metab 2016; 101: 4512–4520.
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14. Cermak J, Howard R, Ubaldi N, Jeeves J. Women in leadership: lessons from Australian companies leading the way; January 2018 report. McKinsey, 2018. https://www.mckinsey.com/featured-insights/gender-equality/women-in-leadership-lessons-from-australian-companies-leading-the-way (viewed Oct 2018).
15. Levinson W, Lurie N. When most doctors are women: what lies ahead? Ann Intern Med 2004; 141: 471–474.
16. Morahan PS, Rosen SE, Richman RC, et al. The leadership continuum: a framework for organizational and individual assessment relative to the advancement of women physicians and scientists. J Womens Health 2011; 20: 387–396.
17. Arvey RD, Zhang Z, Avolio BJ, et al. Developmental and genetic determinants of leadership role occupancy among women. J Appl Psychol 2007; 92: 693–706.
18. Koenig AM, Eagly AH, Mitchell AA, et al. Are leader stereotypes masculine? A meta‐analysis of three research paradigms. Psychol Bull 2011; 137: 616–642.
19. Athanasiou T, Patel V, Garas G, et al. Mentoring perception, scientific collaboration and research performance: is there a “gender gap” in academic medicine? An Academic Health Science Centre perspective. Postgrad Med J 2016; 92: 581–586.

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Narrative review

Infections in pregnancy

Caitlin L Keighley, Hannah JM Skrzypek, Angela Wilson, Michael A Bonning and Gwendolyn L Gilbert

Med J Aust 2019; 211 (3): . || doi: 10.5694/mja2.50261
Published online: 5 August 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Women's health

Infectious diseases

Pediatric medicine

Summary

Infections in pregnancy represent a challenging and often underappreciated area of concern for many specialists and general practitioners and can cause serious sequelae.
Antenatal status should be highlighted on pathology request forms, as this serves to alert the laboratory of the need to store serum for an extended period. Prior antenatal specimens can be forwarded to other laboratories to enable testing in parallel with the more recent sample.
Women with a confirmed, potentially vertically transmissible infection should be referred to a specialist with expertise in the management of perinatal infections.
Cytomegalovirus infection is the most common congenital infection. Women who care for young children are at greater risk of exposure to the virus. Preventive steps including hand hygiene and avoiding contact with children's urine, mucous and saliva are recommended for all pregnant women.
The incidence of parvovirus B19 infection in pregnancy is unknown. This infection is highly contagious and may result in fetal loss; particularly in the first half of pregnancy, pregnant women should avoid contact with adults or children who may have an infection.

1 Institute for Clinical Pathology and Medical Research, NSW Health Pathology Centre for Infectious Diseases and Microbiology, Sydney, NSW
2 University of Sydney, Sydney, NSW
3 Mercy Hospital for Women, Melbourne, VIC
4 Alice Springs Hospital, Alice Springs, NT
5 GP Synergy, Sydney, NSW
6 Macquarie University, Sydney, NSW
7 Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW
8 Sydney Health Ethics, University of Sydney, Sydney, NSW

Correspondence: Caitlin.Keighley@sydney.edu.au

Competing interests:

No relevant disclosures.

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Position statement

Position statement on the hormonal management of adult transgender and gender diverse individuals

Ada S Cheung, Katie Wynne, Jaco Erasmus, Sally Murray and Jeffrey D Zajac

Med J Aust 2019; 211 (3): . || doi: 10.5694/mja2.50259
Published online: 5 August 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Anatomy and physiology

Sexual health

Abstract

Introduction: Rising demand for gender‐affirming hormone therapy mandates a need for more formalised care of transgender and gender diverse (TGD) individuals in Australia. Estimates suggest that 0.1–2.0% of the population are TGD, yet medical education in transgender health is lacking. We aim to provide general practitioners, physicians and other medical professionals with specific Australian recommendations for the hormonal and related management of adult TGD individuals.

Main recommendations:

Hormonal therapy is effective at aligning physical characteristics with gender identity and in addition to respectful care, may improve mental health symptoms.
Masculinising hormone therapy options include transdermal or intramuscular testosterone at standard doses.
Feminising hormone therapy options include transdermal or oral estradiol. Additional anti‐androgen therapy with cyproterone acetate or spironolactone is typically required.
Treatment should be adjusted to clinical response. For biochemical monitoring, target estradiol and testosterone levels in the reference range of the affirmed gender.
Monitoring is suggested for adverse effects of hormone therapy.
Preferred names in use and pronouns should be used during consultations and reflected in medical records.
While being TGD is not a mental health disorder, individualised mental health support to monitor mood during medical transition is recommended.

Changes in management as result of this position statement: Gender‐affirming hormone therapy is effective and, in the short term, relatively safe with appropriate monitoring. Further research is needed to guide clinical care and understand long term effects of hormonal therapies. We provide the first guidelines for medical practitioners to aid the provision of gender‐affirming care for Australian adult TGD individuals.

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1 Austin Health, University of Melbourne, Melbourne, VIC
2 Diabetes and Endocrinology, Hunter New England Health, Newcastle, NSW
3 Gender Clinic, Monash Health, Melbourne, VIC
4 Sexual Health Service, Royal Perth Hospital, Perth, WA

Correspondence: adac@unimelb.edu.au

Acknowledgements:

The figure in Box 2 was designed for this article by graphic artist Jake Kidson‐Purry. We thank TGD community members who reviewed and provided feedback on the position statement: Daria Chetcuti, Max Rainier, Alex Wong andTransgender Victoria committee members. We also thank expert reviewers Ruth McNair (University of Melbourne), Michael Irwig (George Washington University, USA), the AusPATH executive committee, the ESA Medical Affairs Committee and the RACP Policy and Advocacy Committee for reviewing the manuscript. Ada Cheung is supported by an Australian Government National Health and Medical Research Council Early Career Fellowship (#1143333) and receives research support from the Viertel Charitable Foundation Clinical Investigator Award, an ESA Postdoctoral Award and the RACP Vincent Fairfax Family Foundation.

Competing interests:

No relevant disclosures.

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Perspectives

The risk of resistance: what are the major antimicrobial resistance threats facing Australia?

Deborah A Williamson, Benjamin P Howden and David L Paterson

Med J Aust 2019; 211 (3): . || doi: 10.5694/mja2.50249
Published online: 5 August 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Infectious diseases

Collaborative systems are required to combat the rising challenge of antimicrobial resistance in health care facilities and the community

These germs of disease have taken toll of humanity since the beginning of things—taken toll of our prehuman ancestors since life began here. But by virtue of this natural selection of our kind we have developed resisting power; to no germs do we succumb without a struggle …

1 Microbiological Diagnostic Unit Public Health Laboratory, Melbourne, VIC
2 Melbourne Health, Melbourne, VIC
3 Centre for Clinical Research, University of Queensland, Brisbane, QLD
4 Infectious Diseases Unit, Royal Brisbane and Women's Hospital, Brisbane, QLD

Correspondence: deborah.williamson@unimelb.edu.au

Acknowledgements:

Deborah Williamson is supported by a National Health and Medical Research Council (NHMRC) Early Career Fellowship (GNT1123854). Benjamin Howden is supported by an NHMRC Practitioner Fellowship (GNT1105905).

Competing interests:

David Patterson has received research grants or honoraria for participation in advisory boards from Shionogi, MSD, Pfizer, Achaogen, Entasis Therapeutics and Accelerate Diagnostics.

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Narrative review

Antiphospholipid syndrome: a clinical review

Veronica Mezhov, Julian D Segan, Huyen Tran and Flavia M Cicuttini

Med J Aust 2019; 211 (4): . || doi: 10.5694/mja2.50262
Published online: 5 August 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Hematologic diseases

Skin and connective tissue diseases

Information science

Pharmaceutical preparations

Immune system diseases

Summary

Antiphospholipid syndrome is characterised by recurrent thrombosis (arterial, venous, microvascular) and/or pregnancy complications in the presence of persistent antiphospholipid antibodies (lupus anticoagulant, anti‐β2‐glycoprotein 1 and anticardiolipin).
It can be a primary disease or associated with another autoimmune disease (especially systemic lupus erythematosis).
Testing for antiphospholipid antibodies should be considered in patients < 50 years of age with unprovoked venous or arterial thromboembolism, thrombosis at unusual sites or pregnancy complications.
The mainstay of treatment is antithrombotic therapy and recommendations vary based on arterial, venous or pregnancy complications.
If associated with systemic lupus erythematosis, hydroxychloroquine is recommended both as primary and secondary prophylaxis.
Antithrombotic treatment is gold standard and effective.

1 Alfred Health, Melbourne, VIC
2 Monash University, Melbourne, VIC

Correspondence: flavia.cicuttini@monash.edu

Acknowledgements:

We thank James McFadyen, Indi Rasaratnam, Juan Aw and Shom Bhattacharjee of Alfred Health for contributing to the content and review of this article.

Competing interests:

Huyen Tran has received grants from Bayer Health and Pfizer and speaker honoraria from Bayer Health and Boehringer Ingelheim.

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