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    Extending the criteria for acceptable organ donors: balancing the risks

    Sakhee Kotecha and Trevor J Williams
    Med J Aust 2019; 211 (9): . || doi: 10.5694/mja2.50370
    Published online: 4 November 2019

    Understanding the low risk of blood‐borne virus infections in donors could help expand the pool of available organs

    Solid organ donation and transplantation rates in Australia have increased in recent years, but demand continues to exceed supply.1 Morbidity and mortality for people on the waiting list remain problems, and strategies to expand the donor pool include accepting donations after circulatory death and adopting extended criteria for acceptable donors.2

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      Nationally linked data to improve health services and policy

      Tom G Briffa, Louisa Jorm, Rodney T Jackson, Christopher Reid and Derek P Chew
      Med J Aust 2019; 211 (9): . || doi: 10.5694/mja2.50368
      Published online: 4 November 2019

      A well designed National Integrated Health Services Information Analysis Asset will improve services and policy

      New Zealand continues to set best practice standards internationally for cardiovascular disease (CVD) risk prediction and management. A 2018 study, using data from the PREDICT general practice cohort linked with demographic, prior medical history and drug‐dispensing data highlighted that the risk of CVD is best estimated from longitudinal follow‐up of a contemporary nationally representative cohort initially free of disease.1 PREDICT is a risk tool that incorporates new predictors of socio‐economic deprivation and ethnicity and better reflects the population whose risk is being assessed. In comparison, the application of earlier international risk equations to Australasian populations, such as the Pooled Cohort Risk Equations (PCEs)2 in the United States and QRISK in the United Kingdom,3 are likely to substantially underestimate or overestimate risk, leading to either undertreatment or overtreatment. Where underestimates of risk occur, the individual is falsely reassured and no indication to commence preventive treatment is apparent. The reverse is true for overestimates of risk, where an indication to start preventive treatment is unnecessary. This is particularly true among socially disadvantaged and ethnically diverse populations, where both PCEs and QRISK underperform. New Zealand's ability to integrate its administrative health datasets with other data sources — in this case, primary care — has enabled the conduct of this policy changing research. The New Zealand's Ministry of Health has adopted and supported the roll‐out of the updated CVD risk management guidelines recommending that general practitioners use the new PREDICT‐derived CVD risk equation. It is thus important that Australia has a national repository that enables the combination of routine health datasets with other data sources, existing and emerging, to permit evaluation of health care and inform policy decisions.


      • 1 University of Western Australia, Perth, WA
      • 2 Centre for Big Data Research in Health, UNSW Sydney, Sydney, NSW
      • 3 University of Auckland, Auckland, New Zealand
      • 4 Curtin University, Perth, WA
      • 5 Flinders University, Adelaide, SA


      Correspondence: tom.briffa@uwa.edu.au
      Competing interests:

      No relevant disclosures.

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        Pilot trial of digital breast tomosynthesis (3D mammography) for population‐based screening in BreastScreen Victoria

        Nehmat Houssami, Darren Lockie, Michelle Clemson, Vicki Pridmore, David Taylor, Georgina Marr, Jill Evans and Petra Macaskill
        Med J Aust 2019; 211 (8): . || doi: 10.5694/mja2.50320
        Published online: 21 October 2019

        Abstract

        Objectives: To estimate detection measures for tomosynthesis and standard mammography; to assess the feasibility of using tomosynthesis in population‐based screening for breast cancer.

        Design, setting: Prospective pilot trial comparing tomosynthesis (with synthesised 2D images) and standard mammography screening of women attending Maroondah BreastScreen, a BreastScreen Victoria service in the eastern suburbs of Melbourne.

        Participants: Women at least 40 years of age who presented for routine breast screening between 18 August 2017 and 8 November 2018.

        Main outcome measures: Cancer detection rate (CDR); proportion of screens that led to recall for further assessment.

        Results: 5018 tomosynthesis and 5166 standard mammography screens were undertaken in 10 146 women; 508 women (5.0% of screens) opted not to undergo tomosynthesis screening. With tomosynthesis, 49 cancers (40 invasive, 9 in situ) were detected (CDR, 9.8 [95% CI, 7.2–13] per 1000 screens); with standard mammography, 34 cancers (30 invasive, 4 in situ) were detected (CDR, 6.6 [95% CI, 4.6–9.2] per 1000 screens). The estimated difference in CDR was 3.2 more detections (95% CI, –0.32 to 6.8) per 1000 screens with tomosynthesis; the difference was greater for repeat screens and for women aged 60 years or more. The recall rate was greater for tomosynthesis (4.2%; 95% CI, 3.6–4.8%) than standard mammography (3.0%; 95% CI, 2.6–3.5%; estimated difference, 1.2%; 95% CI, 0.46–1.9%). The median screen reading time for tomosynthesis was 67 seconds (interquartile range [IQR] 46–105 seconds); for standard mammography, 16 seconds (IQR, 10–29 seconds).

        Conclusions: Breast cancer detection, recall for assessment, and screen reading time were each higher for tomosynthesis than for standard mammography. Our preliminary findings could form the basis of a large scale comparative evaluation of tomosynthesis and standard mammography for breast screening in Australia.

        Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12617000947303.

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        • 1 Sydney School of Public Health, University of Sydney, Sydney, NSW
        • 2 Eastern Health Breast and Cancer Centre, Melbourne, VIC
        • 3 BreastScreen Victoria, Melbourne, VIC
        • 4 Box Hill Hospital, Melbourne, VIC


        Acknowledgements: 

        The study was funded by a National Breast Cancer Foundation (NBCF) Australia pilot study grant. Nehmat Houssami is funded by an NBCF Breast Cancer Research Leadership Fellowship. We thank Sue Viney and John Heggie for important contributions to our study. We thank the radiology, radiography, data and administrative staff at Maroondah BreastScreen, and also thank the information technology staff, the client communications and recruitment team, and the data management staff at BreastScreen Victoria for helping us implement the trial. We thank the women who attended Maroondah BreastScreen and participated in the study.

        Competing interests:

        No relevant disclosures.

        • 1. Lauby‐Secretan B, Scoccianti C, Loomis D, et al; International Agency for Research on Cancer Handbook Working Group. Breast‐cancer screening: viewpoint of the IARC Working Group. N Engl J Med 2015; 372: 2353–2358.
        • 2. Nelson HD, Fu R, Cantor A, et al. Effectiveness of breast cancer screening: systematic review and meta‐analysis to update the 2009 US Preventive Services Task Force recommendation. Ann Int Med 2016; 164: 244–255.
        • 3. Marmot MG, Altman DG, Cameron DA, et al. The benefits and harms of breast cancer screening: an independent review. Br J Cancer 2013; 108: 2205–2240.
        • 4. Houssami N, Miglioretti DL. Digital breast tomosynthesis: a brave new world of mammography screening. JAMA Oncol 2016; 2: 725–727.
        • 5. Ciatto S, Houssami N, Bernardi D, et al. Integration of 3D digital mammography with tomosynthesis for population breast‐cancer screening (STORM): a prospective comparison study. Lancet Oncol 2013; 14: 583–589.
        • 6. Marinovich ML, Hunter KE, Macaskill P, Houssami N. Breast cancer screening using tomosynthesis or mammography: a meta‐analysis of cancer detection and recall. J Natl Cancer Inst 2018; 110: 942–949.
        • 7. Zackrisson S, Lång K, Rosso A, et al. One‐view breast tomosynthesis versus two‐view mammography in the Malmo Breast Tomosynthesis Screening Trial (MBTST): a prospective, population‐based, diagnostic accuracy study. Lancet Oncol 2018; 19: 1493–1503.
        • 8. Pattacini P, Nitrosi A, Giorgi Rossi P, et al; RETomo Working Group. Digital mammography versus digital mammography plus tomosynthesis for breast cancer screening: the Reggio Emilia tomosynthesis randomized trial. Radiology 2018; 288: 375–385.
        • 9. Australian Institute of Health and Welfare. BreastScreen Australia monitoring report 2014–2015 (Cat. No. CAN 105; Cancer series no. 106). Canberra: Australian Institute of Health and Welfare, 2017.
        • 10. Yun SJ, Ryu CW, Rhee SJ, et al. Benefit of adding digital breast tomosynthesis to digital mammography for breast cancer screening focused on cancer characteristics: a meta‐analysis. Breast Cancer Res Treat 2017; 164: 557–569.
        • 11. Bernardi D, Macaskill P, Pellegrini M, et al. Breast cancer screening with tomosynthesis (3D mammography) with acquired or synthetic 2D mammography compared with 2D mammography alone (STORM‐2): a population‐based prospective study. Lancet Oncol 2016; 17: 1105–1113.
        • 12. Houssami N, Lee CI. The impact of legislation mandating breast density notification: review of the evidence. Breast 2018; 42: 102–112.
        • 13. Bernardi D, Ciatto S, Pellegrini M, et al. Application of breast tomosynthesis in screening: incremental effect on mammography acquisition and reading time. Br J Radiol 2012; 85: e1174–e1178.
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          Including ethnic and cultural diversity in dementia research

          Lee‐Fay Low, Annica L Barcenilla‐Wong and Bianca Brijnath
          Med J Aust 2019; 211 (8): . || doi: 10.5694/mja2.50353
          Published online: 21 October 2019

          Australian dementia research needs increased representation of people from culturally and linguistically diverse backgrounds

          Evidence‐based practice and policy must be based on the best available evidence, which should be representative of the population.1 However, the current body of dementia research does not reflect the ethnic and cultural diversity of the Australian population. Hence, people from culturally and linguistically diverse (CALD) backgrounds may receive inequitable dementia care as there is less evidence to help optimise clinical and service decisions.


          • 1 University of Sydney, Sydney, NSW
          • 2 National Ageing Research Institute, Melbourne, VIC
          • 3 Monash University, Melbourne, VIC


          Acknowledgements: 

          The data presented in this article were funded by the NNIDR as part of the development of the CALD Dementia Research Roadmap. Lee‐Fay Low is funded through an NHMRC Boosting Dementia Research Leadership Development Fellowship. The NNIDR were involved in conceptualising the article, but not in analysis or interpretation.

          Competing interests:

          Bianca Brijnath has financial relationships with government and private foundations for research and policy development specific to CALD communities and dementia.

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          • 30. Brewster P, Barnes L, Haan M, et al. Progress and future challenges in aging and diversity research in the United States. Alzheimers Dement 2019; 15: 995–1003.
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            Responding to mandatory immigration detention: lessons for the health care community

            Ryan Essex and David Isaacs
            Med J Aust 2019; 211 (9): . || doi: 10.5694/mja2.50366
            Published online: 14 October 2019

            After 25 years of advocacy, what can the health care community learn from recent reforms of Australian immigration detention?

            In February 2019, the Australian Government announced that it had removed all refugee and asylum seeker children from offshore detention in Nauru.1 Soon after, the Australian Parliament passed the Migration Amendment (Urgent Medical Treatment) Bill 2018.2 This legislation strengthens the position of doctors to recommend a transfer of an ill person to Australia for treatment from offshore detention centres in Manus Island (Papua New Guinea) and Nauru. While this has been welcome news, these developments are tempered by the fact that the government is seeking to repeal this legislation and has maintained an increasingly combative stance on these issues.


            • 1 University of Sydney, Sydney, NSW
            • 2 University of Greenwich, London, UK
            • 3 Barts Health NHS Trust, London, UK
            • 4 Children's Hospital at Westmead, Sydney, NSW


            Correspondence: r.w.essex@gre.ac.uk
            Competing interests:

            No relevant disclosures.

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              Frailty in very old critically ill patients in Australia and New Zealand: a population‐based cohort study

              Jai N Darvall, Rinaldo Bellomo, Eldho Paul, Ashwin Subramaniam, John D Santamaria, Sean M Bagshaw, Sumeet Rai, Ruth E Hubbard and David Pilcher
              Med J Aust 2019; 211 (7): . || doi: 10.5694/mja2.50329
              Published online: 7 October 2019

              Abstract

              Objective: To explore associations between frailty (Clinical Frailty Scale score of 5 or more) in very old patients in intensive care units (ICUs) and their clinical outcomes (mortality, discharge destination).

              Design, setting and participants: Retrospective population cohort analysis of Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database data for all patients aged 80 years or more admitted to participating ICUs between 1 January 2017 and 31 December 2018.

              Main outcome measures: Primary outcome: in‐hospital mortality; secondary outcomes: length of stay (hospital, ICU), re‐admission to ICU during the same hospital admission, discharge destination (including new chronic care or nursing home admission).

              Results: Frailty status data were available for 15 613 of 45 773 patients aged 80 years or more admitted to 178 ICUs (34%); 6203 of these patients (39.7%) were deemed frail. A smaller proportion of frail than non‐frail patients were men (47% v 57%), the mean illness severity scores of frail patients were slightly higher than those of non‐frail patients, and they were more frequently admitted from the emergency department (28% v 21%) or with sepsis (12% v 7%) or respiratory complications (16% v 12%). In‐hospital mortality was higher for frail patients (17.6% v 8.2%; adjusted odds ratio [OR], 1.87 [95% CI, 1.65–2.11]). Median lengths of ICU and hospital stay were slightly longer for frail patients, and they were more frequently discharged to new nursing home or chronic care (4.9% v 2.8%; adjusted OR, 1.61 [95% CI, 1.34–1.95]).

              Conclusions: Many very old critically ill patients in Australia and New Zealand are frail, and frailty is associated with considerably poorer health outcomes. Routine screening of older ICU patients for frailty could improve outcome prediction and inform intensive care and community health care planning.

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              • 1 Royal Melbourne Hospital, Melbourne, VIC
              • 2 Centre for Integrated Critical Care, University of Melbourne, Melbourne, VIC
              • 3 Austin Hospital, Melbourne, VIC
              • 4 Monash University, Melbourne, VIC
              • 5 Peninsula Health, Melbourne, VIC
              • 6 Peninsula Clinical School, Monash University, Melbourne, VIC
              • 7 St Vincent's Hospital Melbourne, Melbourne, VIC
              • 8 University of Alberta, Edmonton, AB, Canada
              • 9 ANU Medical School, Australian National University, Canberra, ACT
              • 10 Canberra Hospital, Canberra, ACT
              • 11 Centre for Health Services Research, University of Queensland, Brisbane, QLD
              • 12 The Alfred Hospital, Melbourne, VIC
              • 13 Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC


              Correspondence: jai.darvall@mh.org.au
              Acknowledgements: 

              Sean Bagshaw is supported by a Canada Research Chair in Critical Care Nephrology.

              Competing interests:

              No relevant disclosures.

              • 1. Australian Bureau of Statistics. 3222.0. Population projections, Australia, 2017 (base) – 2066. Nov 2018. https://www.abs.gov.au/AUSSTATS/abs@.nsf/mf/3222.0 (viewed July 2019).
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              • 23. Darvall JN, Boonstra T, Norman J, et al. Retrospective frailty determination in critical illness from review of the ICU clinical record. Anaesth Intensive Care 2019; 36: 1–6.
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                Difficulties in knowing which critical care trial data warrant change in practice

                Benjamin Reddi, Mark Finnis and Sandra Peake
                Med J Aust 2019; 211 (7): . || doi: 10.5694/mja2.50331
                Published online: 7 October 2019

                Why is some strong evidence ignored while some weak evidence is rapidly acted upon?

                Most clinicians aspire to practise evidence‐based medicine, no longer believing it acceptable to implement novel interventions simply because they “make sense” or remain untested. However, external influences, psychological factors, and misapplied statistical techniques may hinder rational decision making. Using examples from intensive care literature, we discuss why well supported therapies are not always readily adopted, while poorly supported interventions may be unduly welcomed into practice.


                • 1 Royal Adelaide Hospital, Adelaide, SA
                • 2 Queen Elizabeth Hospital, Adelaide, SA


                Correspondence: Benjamin.Reddi@sa.gov.au
                Competing interests:

                No relevant disclosures.

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                  Towards gender balance in the Australian intensive care medicine workforce

                  Lucy J Modra and Sarah A Yong
                  Med J Aust 2019; 211 (7): . || doi: 10.5694/mja2.50330
                  Published online: 7 October 2019

                  Achieving gender equity in intensive care medicine requires specific interventions to attract and retain female trainees and support their progress to leadership roles

                  For several decades, women have comprised about half of medical graduates in Australia.1 This is yet to translate into a gender‐balanced specialty workforce. In 2016, fewer than one in five practising surgeons, cardiologists and intensivists were women.2 In recognition of this, several Colleges have developed plans to improve gender balance within their specialty.


                  • 1 Austin Health, Melbourne, VIC
                  • 2 Alfred Health, Melbourne, VIC
                  • 3 Monash University, Melbourne, VIC


                  Correspondence: Lucy.MODRA@austin.org.au
                  Competing interests:

                  Lucy Modra and Sarah Yong are founding convenors of the WIN‐ANZICS Committee.

                  • 1. Australian Government Department of Health. Medical Training Review Panel: nineteenth report. May 2016. Canberra: Commonwealth of Australia, 2016. https://www.health.gov.au/internet/main/publishing.nsf/Content/work-pubs-mtrp-19 (viewed June 2019).
                  • 2. Australian Government Department of Health. National Health Workforce Dataset. Medical fact sheets 2016 https://hwd.health.gov.au/publications.html (viewed June 2019).
                  • 3. Modra LJ, Yong SA, Austin DE. Women in leadership in intensive care medicine. ICU Manage Pract 2016; 16: 174–176.
                  • 4. Venkatesh B, Mehta S, Angus DC, et al. Women in Intensive Care study: a preliminary assessment of international data on female representation in the ICU physician workforce, leadership and academic positions. Crit Care 2018; 22: 211.
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                  • 7. College of Intensive Care Medicine of Australia and New Zealand. Statement on gender balance within the College of Intensive Care Medicine. IC‐28 (2019). https://www.cicm.org.au/CICM_Media/CICMSite/CICM-Website/Resources/Professional%20Documents/IC28-Statement-On-Gender-Balance-Within-The-College-Of-Intensive-Care-Medicine_1.pdf (viewed June 2019).
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                    Equity for Indigenous Australians in intensive care

                    Paul J Secombe, Alex Brown, Michael J Bailey and David Pilcher
                    Med J Aust 2019; 211 (7): . || doi: 10.5694/mja2.50339
                    Published online: 7 October 2019

                    The similarity in mortality among Indigenous and non‐Indigenous critically ill patients hides a complex story

                    Aboriginal and Torres Strait Islander Australians are more likely to be admitted to acute care hospitals than non‐Indigenous Australians.1 While this is widely recognised, the over‐representation of Indigenous patients in Australian intensive care units (ICUs) has been highlighted only recently.2,3 The headline finding that Indigenous Australians have an ICU admission rate that is 1.2 times the expected rate considering population representation is concerning, although not surprising, given higher Indigenous hospitalisation rates.1,2,3 It is reassuring that Indigenous patients appear to have similar in‐ICU and in‐hospital mortality.2,3 Intensivists should be justifiably proud of this mortality equivalence, but deeper analysis conveys some inconvenient truths.

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                    • 1 Alice Springs Hospital, Alice Springs, NT
                    • 2 Monash University, Melbourne, VIC
                    • 3 South Australian Health and Medical Research Institute, Adelaide, SA
                    • 4 University of South Australia, Adelaide, SA
                    • 5 Alfred Health, Melbourne, VIC
                    • 6 Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC


                    Correspondence: paulsecombe@bigpond.com
                    Competing interests:

                    No relevant disclosures.

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                      The evolving role of intensive care in health care and society

                      Stephen Warrillow and Raymond Raper
                      Med J Aust 2019; 211 (7): . || doi: 10.5694/mja2.50340
                      Published online: 7 October 2019
                      Correction(s) for this article: Erratum | Published online: 4 April 2025

                      Despite the evolving needs of patients and changing societal expectations, Australasian intensive care continues to provide a world leading service to patients and the broader society

                      With Melbourne hosting the 2019 World Congress of Intensive Care, it is timely to reflect on the nature of the speciality and consider its role within health care. The intensive care unit (ICU) can be a daunting place. For patients, families and even non‐intensive care clinicians, the complex and technically advanced environment can feel intimidating. The ICU represents a microcosm of the broader acute health care system, where the challenges of patient‐centred care, treatment, communication and resource management are encountered in a more impactful setting. The reach of intensive care is wide; current estimates from the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation suggest that Australians and New Zealanders have a 50% lifetime chance of requiring admission to an ICU.1 Intensive care interacts with every other element of acute care, serving the needs of patients, specialist units, hospitals and broader society. In its more recent history, intensive care has evolved to encompass more than just a single geographic location; it is an organised system of care that ensures delivery of timely and expert treatment to critically ill patients, increasingly extending this capability beyond the walls of the ICU itself and into many other settings.


                      • 1 Austin Heath, Melbourne, VIC
                      • 2 Australian and New Zealand Intensive Care Society, Melbourne, VIC
                      • 3 University of Melbourne, Melbourne, VIC
                      • 4 College of Intensive Care Medicine of Australia and New Zealand, Melbourne, VIC
                      • 5 Royal North Shore Hospital, Sydney, NSW


                      Competing interests:

                      Stephen Warrilow is President of the Australian and New Zealand Intensive Care Society and Convenor of the 2019 World Congress of Intensive Care. Raymond Raper is President of the CICM.

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