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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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      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: 7 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.

      • 1. Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation. Adult patient database. https://www.anzics.com.au/adult-patient-database-apd/ (viewed July 2019).
      • 2. Lichtenberg FR. The impact of biomedical innovation on longevity and health. Nordic J Health Econ 2015; 5: 45–57.
      • 3. Montgomery H, Grocott M, Mythen M. Critical care at the end of life: balancing technology with compassion and agreeing when to stop. Br J Anaesth 2017; 119 Suppl 1: i85–i89.
      • 4. Bagshaw SM, Webb SAR, Delaney A, et al. Very old patients admitted to intensive care in Australia and New Zealand: a multi‐centre cohort analysis. Crit Care 2009; 13: R45.
      • 5. Muscedere J, Waters B, Varambally A, et al. The impact of frailty on intensive care unit outcomes: a systematic review and meta‐analysis. Intensive Care Med 2017; 43: 1105–1122.
      • 6. Darvall JN, Bellomo R, Paul E, et al. Frailty in very old critically ill patients in Australia and New Zealand: a population‐based cohort study. Med J Aust 2019; 211: 318–323.
      • 7. Corke C, Leeuw E, Lo SK, George C. Predicting future intensive care demand in Australia. Crit Care Resusc. 2009; 11: 257–260.
      • 8. Melville A, Kolt G, Anderson D, et al. Admission to intensive care for palliative care or potential organ donation: demographics, circumstances, outcomes, and resource use. Crit Care Med 2017; 45: e1050–e1059.
      • 9. Hicks P, Huckson S, Fenny E, et al. The financial cost of intensive care in Australia: a multicentre registry study. Med J Aust 2019; 211: 324–325.
      • 10. Prin M, Wunsch H. International comparisons of intensive care: informing outcomes and improving standards. Curr Opin Crit Care 2012; 18: 700–706.
      • 11. Hillman KM, Chen J, Jones D. Rapid response systems. Med J Aust 2014; 201: 519–521. https://www.mja.com.au/journal/2014/201/9/rapid-response-systems
      • 12. Lasiter S, Oles SK, Mundell J, et al. Critical care follow‐up clinics: a scoping review of interventions and outcomes. Clin Nurse Spec. 2016; 30: 227–237.
      • 13. Hilton AK, Jones D, Bellomo R. Clinical review: the role of the intensivist and the rapid response team in nosocomial end‐of‐life care. Crit Care 2013; 17: 224.
      • 14. Marini JJ. Re‐tooling critical care to become a better intensivist: something old and something new. Crit Care 2015; 19 Suppl 3: S3.
      • 15. 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.
      • 16. Modra LJ, Yong SA. Towards gender balance in the Australian intensive care medicine workforce. Med J Aust 2019; 211: 300–302.
      • 17. Warrillow S, Farley KJ, Jones D. How to improve communication quality with patients and relatives in the ICU. Minerva Anestesiol 2016; 82: 797–803.
      • 18. Anesi GL, Wagner J, Halpern SD. intensive care medicine in 2050: toward an intensive care unit without waste. Intensive Care Med 2017; 43: 554–556.
      • 19. Warrillow S, Farley K, Jones D. Ten practical strategies for effective communication with relatives of ICU patients. Intensive Care Med 2015; 41: 2173–2176.
      • 20. Bellomo R, Stow PJ, Hart GK. Why is there such a difference in outcome between Australian intensive care units and others? Curr Opin Anaesthesiol 2007; 20: 100–105.
      • 21. Peake S, Delaney A, French CJ. Evolution not revolution: the future of the randomised controlled trial in intensive care research. Med J Aust 2019; 211: 303–305.
      • 22. Haines KJ, Berney S, Warrillow S, Denehy L. Long‐term recovery following critical illness in an Australian cohort. J Intensive Care 2018; 6: 8.
      • 23. Secombe PJ, Brown A, Bailey MJ, Picher D. Diversity and equity within critical care: Indigenous Australians in intensive care. Med J Aust 2019; 211: 297–299.
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        Clinically important sport‐related traumatic brain injuries in children

        Nitaa Eapen, Gavin A Davis, Meredith L Borland, Natalie Phillips, Ed Oakley, Stephen Hearps, Amit Kochar, Sarah Dalton, John Cheek, Jeremy Furyk, Mark D Lyttle, Silvia Bressan, Louise Crowe, Stuart Dalziel, Emma Tavender and Franz E Babl
        Med J Aust 2019; 211 (8): . || doi: 10.5694/mja2.50311
        Published online: 30 September 2019

        Sports participation by children and adolescents is generally high in Australia and New Zealand,1,2 and many children sustain head injuries of varying severity during such activities. Concussion has received increasing attention, but less is known about the risk of severe acute intracranial injuries in children with sports‐related head injuries.3

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        • 1 Royal Children's Hospital, Melbourne, VIC
        • 2 Murdoch Children's Research Institute, Melbourne, VIC
        • 3 University of Melbourne, Melbourne, VIC
        • 4 Perth Children's Hospital, Perth, WA
        • 5 University of Western Australia, Perth, WA
        • 6 Queensland Children's Hospital, Brisbane, QLD
        • 7 Children's Health Research Centre, University of Queensland, Brisbane, QLD
        • 8 Women's and Children's Hospital, Adelaide, SA
        • 9 Children's Hospital at Westmead, Sydney, NSW
        • 10 The Townsville Hospital, Townsville, QLD
        • 11 Bristol Royal Hospital for Children, Bristol, United Kingdom
        • 12 University of Padova, Padova, Italy
        • 13 Starship Children's Health, Auckland, New Zealand
        • 14 University of Auckland, Auckland, New Zealand


        Correspondence: franz.babl@rch.org.au
        Acknowledgements: 

        The study was funded by grants from the National Health and Medical Research Council (NHMRC; project grant GNT1046727, Centre of Research Excellence for Paediatric Emergency Medicine GNT1058560); the Murdoch Children's Research Institute, Melbourne; the Emergency Medicine Foundation, Brisbane (EMPJ‐11162); Perpetual Philanthropic Services (2012/1140); Auckland Medical Research Foundation (3112011) and the A + Trust (Auckland District Health Board); WA Health Targeted Research Funds 2013; and the Townsville Hospital and Health Service Private Practice Research and Education Trust Fund; and was supported by the Victorian Government Infrastructure Support Program. Franz Babl was partly funded by an NHMRC Practitioner Fellowship and a Melbourne Campus Clinician Scientist fellowship. Stuart Dalziel was partly funded by the Health Research Council of New Zealand (HRC13/556).

        Competing interests:

        No relevant disclosures.

        • 1. Australian Bureau of Statistics. 4156.0. Sports and physical recreation: a statistical overview, 2012. Dec 2012. http://www.abs.gov.au/ausstats/abs@.nsf/Products/76DF25542EE96D12CA257AD9000E2685?opendocument (viewed Sept 2018).
        • 2. Brocklesby J, McCarty G., Active NZ. Main report — the New Zealand Participation Survey 2017. Wellington: Sport New Zealand, 2018. https://sportnz.org.nz/assets/Uploads/Main-Report.pdf (viewed Sept 2018).
        • 3. Davies GA, Anderson V, Babl FE, et al. What is the difference in concussion management in children as compared with adults? A systematic review. Br J Sports Med 2017; 51: 949–957.
        • 4. Babl FE, Borland ML, Phillips N, et al. Paediatric Research in Emergency Departments International Collaborative (PREDICT). Accuracy of PECARN, CATCH and CHALICE head injury decision rules in children: a prospective cohort study. Lancet 2017; 389: 2393–2402.
        • 5. Kuppermann N, Holmes JF, Dayan PS, et al. Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically‐important traumatic brain injuries after head trauma: a prospective cohort study. Lancet 2009; 374: 1160–1170.
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          Health care for older people in rural and remote Australia: challenges for service provision

          Fergus W Gardiner, Alice M Richardson, Lara Bishop, Abby Harwood, Elli Gardiner, Lauren Gale, Narcissus Teoh, Robyn M Lucas and Martin Laverty
          Med J Aust 2019; 211 (8): . || doi: 10.5694/mja2.50277
          Published online: 30 September 2019

          Many Australians living in rural and remote areas of Australia need to travel hundreds of kilometres for health care service, or to wait for health service providers, such as the Royal Flying Doctor Service (RFDS), to visit them. The levels of acute and subacute hospital services in rural and remote areas are reported to be inadequate,1 as is, to a lesser extent, access to aged care services.2 The need to travel long distances is a major barrier for people in remote locations, particularly older people, seeking health care.

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          • 1 Royal Flying Doctor Service of Australia, Canberra, ACT
          • 2 National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, ACT
          • 3 College of Health and Medicine, Australian National University, Canberra, ACT
          • 4 Royal Flying Doctor Service, Queensland Section, Cairns, QLD


          Correspondence: fergus.gardiner@rfds.org.au
          Competing interests:

          No relevant disclosures.

          • 1. Davis J, Morgans A, Stewart J. Developing an Australian health and aged care research agenda: a systematic review of evidence at the subacute interface. Aust Health Rev 2016; 40: 420–427.
          • 2. van Gaans D, Dent E. Issues of accessibility to health services by older Australians: a review. Public Health Rev 2018; 39: 20.
          • 3. Australian Institute of Health and Welfare. Older Australia at a glance (AGE 87). Canberra: AIHW, 2018. https://www.aihw.gov.au/reports/older-people/older-australia-at-a-glance (viewed June 2019).
          • 4. Gardiner FW, Gale L, Bishop L, Laverty M. Healthy ageing in rural and remote Australia: challenges and gaps in service provision to overcome. Canberra: The Royal Flying Doctor Service of Australia, 2018. https://www.flyingdoctor.org.au/assets/documents/RN069_Healthy_Ageing_Report_D3.pdf (viewed June 2019).
          • 5. Cui X, Zhou X, Ma LL, et al. A nurse‐lead structured education program improves self‐management skills and reduces hospital readmissions in patients with chronic heart failure: a randomized and controlled trial. Rural Remote Health 2019; 19: 5270.
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            First reported case of extensively drug‐resistant typhoid in Australia

            Annaleise Howard‐Jones, Alison M Kesson, Alexander C Outhred and Philip N Britton
            Med J Aust 2019; 211 (6): . || doi: 10.5694/mja2.50316
            Published online: 16 September 2019

            To the Editor: The period from January to March marks the peak season for travellers returning to Australia, and typhoid is a key illness of concern. Since 2016, an extensively drug‐resistant (XDR) typhoid clade has emerged in Pakistan, showing resistance to all first‐line agents.1,2 Over the past 2 years, seven cases have been reported in returned travellers — mostly children — from Pakistan to England, Germany and the United States.1,3,4


            • 1 Children's Hospital at Westmead, Sydney, NSW
            • 2 University of Sydney, Sydney, NSW


            Competing interests:

            No relevant disclosures.

            • 1. Klemm EJ, Shakoor S, Page AJ, et al. Emergence of an extensively drug‐resistant Salmonella enterica serovar Typhi clone harboring a promiscuous plasmid encoding resistance to fluoroquinolones and third‐generation cephalosporins. MBio 2018; 9: pii e00105‐18.
            • 2. World Health Organization. Disease outbreaks in Eastern Mediterranean Region (EMR), January to December 2018. WHO EMRO Weekly Epidemiology Monitor 2018; 11: 1. http://applications.emro.who.int/docs/epi/2018/Epi_Monitor_2018_11_52.pdf?ua=1 (viewed July 2019).
            • 3. Chatham‐Stephens K, Medalla F, Hughes M, et al. Emergence of extensively drug‐resistant Salmonella Typhi infections among travelers to or from Pakistan — United States, 2016–2018. MMWR Morb Mortal Wkly Rep 2019; 68: 11–13.
            • 4. Kleine CE, Schlabe S, Hischebeth GTR, Molitor E, Pfeifer Y, Wasmuth JC, et al. Successful therapy of a multidrug‐resistant extended‐spectrum β‐lactamase‐producing and fluoroquinolone‐resistant Salmonella enterica Subspecies enterica serovar Typhi infection using combination therapy of meropenem and fosfomycin. Clin Infect Dis 2017; 65: 1754–1756.
            • 5. Khatami A, Khan F, Macartney KK. Enteric fever in children in Western Sydney, Australia, 2003–2015. Pediatr Infect Dis J 2017; 36: 1124–1128.
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              Pulmonary challenges of prolonged journeys to space: taking your lungs to the moon

              G Kim Prisk
              Med J Aust 2019; 211 (6): . || doi: 10.5694/mja2.50312
              Published online: 16 September 2019

              Summary

              • Space flight presents a set of physiological challenges to the space explorer which result from the absence of gravity (or in the case of planetary exploration, partial gravity), radiation exposure, isolation and a prolonged period in a confined environment, distance from Earth, the need to venture outside in the hostile environment of the destination, and numerous other factors.
              • Gravity affects regional lung function, and the human lung shows considerable alteration in function in low gravity; however, this alteration does not result in deleterious changes that compromise lung function upon return to Earth.
              • The decompression stress associated with extravehicular activity, or spacewalk, does not appear to compromise lung function, and future habitat (living quarter) designs can be engineered to minimise this stress.
              • Dust exposure is a significant health hazard in occupational settings such as mining, and exposure to extraterrestrial dust is an almost inevitable consequence of planetary exploration. The combination of altered pulmonary deposition of extraterrestrial dust and the potential for the dust to be highly toxic likely makes dust exposure the greatest threat to the lung in planetary exploration.

              • University of California, San Diego, La Jolla, CA, USA


              Correspondence: kprisk@ucsd.edu
              Acknowledgements: 

              Many of the studies were funded by the National Aeronautics and Space Administration (NASA) and the National Space Biomedical Research Institute under various contracts and grants. G Kim Prisk is currently funded by the National Institutes of Health under R01 HL119263.

              Competing interests:

              No relevant disclosures.

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                Preventing RhD haemolytic disease of the fetus and newborn: where to next?

                James P Isbister and Amanda Thomson
                Med J Aust 2019; 211 (6): . || doi: 10.5694/mja2.50325
                Published online: 16 September 2019

                Non‐invasive fetal RhD genotyping will enable ethical and cost‐effective targeting of prophylaxis

                There are many unique and inspiring aspects to the story of haemolytic disease of the fetus and newborn. This once common, mysterious, and potentially devastating disease has been known for centuries. It may have been the reason for the shocking obstetric history of Katherine of Aragon, the first wife of Henry VIII; the course of British history might have been very different had anti‐RhD been available in Tudor England.1


                • 1 Sydney Medical School, Sydney, NSW
                • 2 Australian Red Cross Blood Service, Sydney, NSW


                Competing interests:

                James Isbister is a member of the Independent Advisory Committee of the Australian Red Cross Blood Service and Chair of the National Blood Authority Patient Blood Management Implementation Steering Committee. Amanda Thompson is a member of the National Blood Authority expert reference group for development of a clinical practice guideline on the use of RhD immunoglobulin in maternity care.

                • 1. Maclennan H. A gynaecologist looks at the Tudors. Med Hist 1967; 11: 66–74.
                • 2. Diamond L, Blackfan K, Baty J. Erythroblastosis fetalis and its association with universal edema of the fetus, icterus gravis neonatorum and anemia of the newborn. J Pediatr 1932; 1: 269–309.
                • 3. Darrow RR. Icterus gravis (erythroblastosis) neonatorum. An examination of etiologic considerations. Arch Pathol 1938; 25: 378–417.
                • 4. Levine P, Burnham L, Katzin EM, Vogel P. The role of iso‐immunization in the pathogenesis of erythroblastosis fetalis. Am J Obstet Gynecol 1941; 42: 925–937.
                • 5. Bowman J. Thirty‐five years of Rh prophylaxis. Transfusion 2003; 43: 1661–1666.
                • 6. McBain RD, Crowther CA, Middleton P. Anti‐D administration in pregnancy for preventing Rhesus alloimmunisation. Cochrane Database Syst Rev 2015; CD000020.
                • 7. Thyer J, Wong J, Thomson A, et al. Fifty years of RhD immunoglobulin (anti‐D) therapy in Australia: celebrating a public health success story. Med J Aust 2018; 209: 336–339.
                • 8. White SW, Cheng JC, Penova‐Veselinovic B, et al. Single dose v  two‐dose antenatal anti‐D prophylaxis: a randomised controlled trial. Med J Aust 2019; 2011: 261–265.
                • 9. Brinc D, Lazarus AH. Mechanisms of anti‐D action in the prevention of hemolytic disease of the fetus and newborn. Hematology Am Soc Hematol Educ Program 2009; 185–191.
                • 10. Breveglieri G, D'Aversa E, Finotti A, et al. Non‐invasive prenatal testing using fetal DNA. Mol Diagn Ther 2019; 23: 291–299.
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                  Public health and economic perspectives on acute rheumatic fever and rheumatic heart disease

                  Jeffrey Cannon, Dawn C Bessarab, Rosemary Wyber and Judith M Katzenellenbogen
                  Med J Aust 2019; 211 (6): . || doi: 10.5694/mja2.50318
                  Published online: 16 September 2019

                  With the care costs for the thousands of new cases predicted to occur by 2031, can we afford “business as usual”?

                  The group A streptococcus (GAS) bacterium causes possibly the most diverse range of diseases compared with any other pathogen. Resulting from an autoimmune reaction to GAS throat infection, and possibly skin infection, acute rheumatic fever (ARF) and its common consequence of rheumatic heart disease (RHD) have been described as “diseases of poverty” because they are highly prevalent in socio‐economic disadvantaged settings.1 Although there is a clear gradient between disease prevalence and socio‐economic disadvantage, ARF and RHD were once also prevalent in low and high socio‐economic settings, including in Melbourne, among non‐Indigenous Australians during the 1930s and 1940s.2 That ARF rarely, if at all, occurs in modern Melbourne is testament to the reality that ARF and RHD can be eliminated Australia‐wide, but what will elimination of ARF and RHD take and can we afford “business as usual”?


                  • 1 Telethon Kids Institute, Perth, WA
                  • 2 Centre for Aboriginal Medical and Dental Health, University of Western Australia, Perth, WA
                  • 3 George Institute for Global Health, Sydney, NSW
                  • 4 Western Australian Centre for Rural Health, University of Western Australia, Perth, WA
                  • 5 Group A Streptococcus and Rheumatic Heart Disease Research Group, Telethon Kids Institute, Perth, WA


                  Competing interests:

                  No relevant disclosures.

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                    Paracetamol poisoning‐related hospital admissions and deaths in Australia, 2004–2017

                    Rose Cairns, Jared A Brown, Claire E Wylie, Andrew H Dawson, Geoffrey K Isbister and Nicholas A Buckley
                    Med J Aust 2019; 211 (5): . || doi: 10.5694/mja2.50296
                    Published online: 2 September 2019

                    Abstract

                    Objectives: To assess the numbers of paracetamol overdose‐related hospital admissions and deaths in Australia since 2007–08, and the overdose size of intentional paracetamol overdoses since 2004.

                    Design, setting: Retrospective analysis of data on paracetamol‐related exposures, hospital admissions, and deaths from the Australian Institute of Health and Welfare National Hospital Morbidity Database (NHMD; 2007–08 to 2016–17), the New South Wales Poisons Information Centre (NSWPIC; 2004–2017), and the National Coronial Information System (NCIS; 2007–08 to 2016–17).

                    Participants: People who took overdoses of paracetamol in single ingredient preparations.

                    Main outcome measures: Annual numbers of reported paracetamol‐related poisonings, hospital admissions, and deaths; number of tablets taken in overdoses.

                    Results: The NHMD included 95 668 admissions with paracetamol poisoning diagnoses (2007–08 to 2016–17); the annual number of cases increased by 44.3% during the study period (3.8% per year; 95% CI, 3.2–4.6%). Toxic liver disease was documented for 1816 of these patients; the annual number increased by 108% during the study period (7.7% per year; 95% CI, 6.0–9.5%). The NSWPIC database included 22 997 reports of intentional overdose with paracetamol (2004–2017); the annual number increased by 77.0% during the study period (3.3% per year; 95% CI, 2.5–4.2%). The median number of tablets taken increased from 15 (IQR, 10–24) in 2004 to 20 (IQR, 10–35) in 2017. Modified release paracetamol ingestion report numbers increased 38% between 2004 and 2017 (95% CI, 30–47%). 126 in‐hospital deaths were recorded in the NHMD, and 205 deaths (in‐hospital and out of hospital) in the NCIS, with no temporal trends.

                    Conclusions: The frequency of paracetamol overdose‐related hospital admissions has increased in Australia since 2004, and the rise is associated with greater numbers of liver injury diagnoses. Overdose size and the proportion of overdoses involving modified release paracetamol have each also increased.

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                    • 1 NSW Poisons Information Centre, Children's Hospital at Westmead, Sydney, NSW
                    • 2 University of Sydney, Sydney, NSW
                    • 3 Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW
                    • 4 Royal Prince Alfred Hospital, Sydney, NSW
                    • 5 University of Newcastle, Newcastle, NSW
                    • 6 Calvary Mater Newcastle, Newcastle, NSW


                    Acknowledgements: 

                    This study was supported by a National Health and Medical Research Council Program Grant (1055176). We acknowledge the Australian Institute of Health and Welfare for providing the National Hospital Morbidity Database data, and the National Coronial Information System (NCIS), managed by the Victorian Department of Justice and Community Safety, for providing the coronial data. We thank the staff of the New South Wales Poisons Information Centre for their contributions to the NSWPIC database.

                    Competing interests:

                    No relevant disclosures.

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                      The increasing use of shave biopsy for diagnosing invasive melanoma in Australia

                      Sara L de Menezes, John W Kelly, Rory Wolfe, Helen Farrugia and Victoria J Mar
                      Med J Aust 2019; 211 (5): . || doi: 10.5694/mja2.50289
                      Published online: 2 September 2019

                      Abstract

                      Objective: To assess changes in the choice of skin biopsy technique for assessing invasive melanoma in Victoria, and to examine the impact of partial biopsy technique on the accuracy of tumour microstaging.

                      Design: Retrospective cross‐sectional review of Victorian Cancer Registry data on invasive melanoma histologically diagnosed in Victoria during 2005, 2010, and 2015.

                      Setting, participants: 400 patients randomly selected from each of the three years, stratified by final tumour thickness: 200 patients with thin melanoma (< 1.0 mm), 100 each with intermediate (1.0–4.0 mm) and thick melanoma (> 4.0 mm).

                      Main outcome measures: Partial and excisional biopsies, as proportions of all skin biopsies; rates of tumour base transection and T‐upstaging, and mean tumour thickness underestimation following partial biopsy.

                      Results: 833 excisional and 337 partial diagnostic biopsies were undertaken. The proportion of partial biopsies increased from 20% of patients in 2005 to 36% in 2015 (P < 0.001); the proportion of shave biopsies increased from 9% in 2005 to 20% in 2015 (P < 0.001), with increasing rates among dermatologists and general practitioners. Ninety‐four of 175 shave biopsies (54%) transected the tumour base; wide local excision subsequently identified residual melanoma in 65 of these cases (69%). Twenty‐one tumours diagnosed by shave biopsy (12%) were T‐upstaged. With base‐transected shave biopsies, tumour thickness was underestimated by a mean 2.36 mm for thick, 0.48 mm for intermediate, and 0.07 mm for thin melanomas.

                      Conclusion: Partial biopsy, particularly shave biopsy, was increasingly used for diagnosing invasive melanoma between 2005 and 2015. Shave biopsy has a high rate of base transection, reducing the accuracy of tumour staging, which is crucial for planning appropriate therapy, including definitive surgery and adjuvant therapy.

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                      • 1 Victorian Melanoma Service, Alfred Hospital, Melbourne, VIC
                      • 2 Monash University Central Clinical School, Melbourne, VIC
                      • 3 Victorian Cancer Registry, Cancer Council Victoria, Melbourne, VIC
                      • 4 Skin and Cancer Foundation, Melbourne, VIC


                      Correspondence: victoria.mar@monash.edu
                      Acknowledgements: 

                      We acknowledge the staff at the Victorian Melanoma Service, Alfred Hospital, and the Victorian Cancer Registry for their support, which made this investigation possible.

                      Competing interests:

                      Victoria Mar received honoraria (speaker’s fees) from Bristol Myers Squibb and Merck in 2018 for work unrelated to this article.

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