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    A perfect storm: fear of litigation for end of life care

    Geoffrey K Mitchell, Lindy Willmott, Ben P White, Donella Piper, David C Currow and Patsy M Yates
    Med J Aust 2019; 210 (10): . || doi: 10.5694/mja2.50164
    Published online: 3 June 2019

    Should doctors fear legal sanction for using opioids at the end of life?

    A perfect storm arises from a rare confluence of adverse meteorological factors, and is a metaphor for an especially bad situation caused by a combination of unfavourable circumstances (www.oed.com). Health care at the end of life has been significantly disturbed by two converging fronts. The first is very public conversations relating to opioid overuse. The second is the current tension between standard end‐of‐life care and voluntary assisted suicide.

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      Respiratory syncytial virus‐associated hospitalisations in Australia, 2006–2015

      Gemma L Saravanos, Meru Sheel, Nusrat Homaira, Aditi Dey, Edward Brown, Han Wang, Kristine Macartney and Nicholas J Wood
      Med J Aust 2019; 210 (10): . || doi: 10.5694/mja2.50159
      Published online: 27 May 2019

      Abstract

      Objective: To estimate rates of respiratory syncytial virus (RSV)‐associated hospitalisation across the age spectrum, and to identify groups at particular risk of serious RSV‐associated disease.

      Design, setting and participants: Retrospective review of National Hospital Morbidity Database data for all RSV‐associated hospitalisations in Australia, 2006–2015.

      Main outcomes and measures: RSV‐coded hospitalisation rates by age, sex, Indigenous status, jurisdiction, and seasonality (month and year); hospital length of stay; in‐hospital deaths.

      Results: During 2006–2015, there were 63 814 hospitalisations with an RSV‐specific principal diagnostic code; 60 551 (94.9%) were of children under 5 years of age. The hospitalisation rate for children under 5 years was 418 per 100 000 population; for children under 6 months of age it was 2224 per 100 000 population; the highest rate was for infants aged 0–2 months (2778 per 100 000 population). RSV‐coded hospitalisation rates were higher for adults aged 65 or more than for people aged 5–64 years (incidence rate ratio [IRR], 6.6; 95% CI, 6.2–7.1), and were also higher for Indigenous Australians than other Australians (IRR, 3.3; 95% CI, 3.2–3.5). A total of 138 in‐hospital deaths were recorded, including 82 of adults aged 65 years or more (59%).

      Conclusions: Prevention strategies targeting infants, such as maternal or early infant vaccination, would probably have the greatest impact in reducing RSV disease rates. Further characterisation of RSV disease epidemiology, particularly in older adults and Indigenous Australians, is needed to inform health care strategies.

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      • 1 National Centre for Research Immunisation and Surveillance, Sydney, NSW
      • 2 The University of Sydney Children's Hospital, Westmead Clinical School, Sydney, NSW
      • 3 School of Women's and Children's Health, University of New South Wales, Sydney, NSW
      • 4 Sydney Children's Hospital Randwick, Sydney, NSW
      • 5 Sydney Medical School, University of Sydney, Sydney, NSW


      Acknowledgements: 

      This study formed part of Gemma Saravanos’ doctoral research at the University of Sydney Children's Hospital at Westmead Clinical School, funded by a University of Sydney Postgraduate Award and supported by the National Centre for Immunisation Research and Surveillance (NCIRS). Nicholas Wood is supported by a National Health and Medical Research Council Career Development Fellowship. We acknowledge the Australian Institute of Health and Welfare for providing the hospitalisation data.

      Competing interests:

      No relevant disclosures.

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        Royal Commission into Aged Care Quality and Safety: the key clinical issues

        Joseph E Ibrahim
        Med J Aust 2019; 210 (10): . || doi: 10.5694/mja2.50168
        Published online: 20 May 2019

        The uncoupling of health care from aged care is a worrying trend


        • Victorian Institute of Forensic Medicine, Monash University, Melbourne, VIC


        Correspondence: Joseph.Ibrahim@monash.edu
        Competing interests:

        No relevant disclosures.

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          Hepatitis B management during immunosuppression for haematological and solid organ malignancies: an Australian consensus statement

          Joseph Doyle, Michelle Raggatt, Monica Slavin, Sue‐Anne McLachlan, Simone I Strasser, Joseph J Sasadeusz, Jessica Howell, Krispin Hajkowicz, Harshal Nandurkar, Anna Johnston, Narin Bak and Alexander J Thompson
          Med J Aust 2019; 210 (10): . || doi: 10.5694/mja2.50160
          Published online: 20 May 2019

          Abstract

          Introduction: Individuals with chronic hepatitis B virus (HBV) infection or past exposure to HBV infection have a substantial risk of reactivation during immunosuppressive cancer therapy. HBV reactivation can lead to liver failure, cancer treatment interruption or death. Clinical concordance with screening and treatment guidelines is inconsistent in practice, and existing international guidelines are not specific to the Australian context. We developed an Australian consensus statement with infectious diseases, hepatology, haematology and oncology specialists to inform hepatitis B screening and antiviral management for immunocompromised patients with haematological and solid organ malignancies in Australia.

          Main recommendations: Recommendations address four key areas of HBV infection management for immunocompromised patients with haematological and solid organ malignancies: who to test for HBV infection, when to start antiviral agents, when to stop antiviral agents, and how to monitor patients during cancer therapy. We recommend testing all patients undergoing cancer treatment for hepatitis B (including HBV surface antigen [HBsAg], HBV core antibody [anti‐HBc], and HBV surface antibody) before cancer treatment. Individuals with chronic HBV infection (HBsAg positive) or past exposure (HBsAg negative and anti‐HBc positive) receiving higher risk chemotherapy require antiviral prophylaxis using entecavir or tenofovir.

          Changes in management as a result of this statement: This consensus statement will simplify the approach to testing and prophylaxis for HBV infection during cancer therapy, and harmonise approaches to discontinuing and monitoring individuals which have been highly variable in practice. We advocate for broader Medicare Benefits Schedule and Pharmaceutical Benefits Scheme access to HBV testing and treatment for patients undergoing cancer therapy.


          • 1 Monash University, Melbourne, VIC
          • 2 Disease Elimination Program, Burnet Institute, Melbourne, VIC
          • 3 Alfred Health, Melbourne, VIC
          • 4 Peter MacCallum Cancer Institute, Melbourne, VIC
          • 5 University of Melbourne, Melbourne, VIC
          • 6 St Vincent's Hospital, Melbourne, VIC
          • 7 AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW
          • 8 University of Sydney, Sydney, NSW
          • 9 Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, VIC
          • 10 Royal Brisbane Hospital, Brisbane, QLD
          • 11 Australian Centre for Blood Diseases, Melbourne, VIC
          • 12 Royal Hobart Hospital, Hobart, TAS
          • 13 University of Tasmania, Hobart, TAS
          • 14 Royal Adelaide Hospital, Adelaide, SA


          Correspondence: Joseph.Doyle@monash.edu
          Competing interests:

          This document was produced independently from industry funding, with support from a competitive funding grant from the Western and Central Melbourne Integrated Cancer Service. Joseph Doyle receives unrelated investigator‐initiated research grants to his institution from Gilead Sciences, AbbVie, Merck/MSD, and Bristol Myers Squibb; received honoraria to his institution for speaking from Gilead Sciences, Merck/MSD, Bristol Myers Squibb, and AbbVie. Simone Strasser received honoraria for advisory boards and speaking from Gilead Sciences, Bristol‐Myers Squibb, AbbVie, MSD, Norgine, Bayer, Eisai, Ipsen, Pfizer, Astellas and Novartis. Joseph Sasadeusz receives research grants from Gilead Sciences. Anna Johnston received honoraria for advisory boards from Roche, Janssen and MSD; and received financial support to attend an education meeting from Roche. Narin Bak receives research grants to his institution from Gilead Sciences for chronic hepatititis B research. Alexander Thompson received research grant support from Gilead Sciences and AbbVie; is a consultant/advisor to Gilead Sciences, AbbVie, BMS, Merck/MSD, Eisai and Bayer; and received honoraria for speaking from Gilead Sciences, AbbVie, Merck/MSD, Bristol‐Myers Squibb and Eli Lilly.

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            Precision health: treating the individual patient with chronic obstructive pulmonary disease

            Ma'en Obeidat, Mohsen Sadatsafavi and Don D Sin
            Med J Aust 2019; 210 (9): . || doi: 10.5694/mja2.50138
            Published online: 20 May 2019

            Summary

            • Chronic obstructive pulmonary disease (COPD) is defined based on a reduced ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) on spirometry. However, within this definition, there is significant heterogeneity of pathophysiological processes that lead to airflow obstruction and variation in phenotypic manifestations across patients.
            • Current pharmacological treatments are based on large randomised clinical trials that apply to an “average” patient.
            • Precision health enables tailoring of treatment for each individual patient by taking into account their unique characteristics.
            • The number needed to treat (NNT) metric is often used to define implementation of precision health for specific interventions, with common endpoints requiring an NNT ≤ 5 to achieve precision therapy. Higher NNTs may be acceptable for rare but important endpoints such as mortality.
            • Long‐acting muscarinic antagonists and inhaled corticosteroids, which are commonly used in COPD, have 1‐year treatment NNTs between 15 and 20 for exacerbation prevention in unselected patients with COPD.
            • Subgroup identification using biomarkers or clinical traits may enable precision health. For example, NNT for inhaled corticosteroids is 9 in patients with a blood eosinophil count ≥ 300 cells/μL and 8 for long‐acting muscarinic antagonists in patients with a body mass index ≤ 20 kg/m2.
            • Lung volume reduction surgery is associated with an NNT of 6 for survival over 5 years in patients with upper lobe‐predominant disease and low exercise capacity (whereas the NNT is 245 when no bioimaging or exercise markers are used). Continuous domiciliary oxygen therapy (for at least 15 hours/day) has an NNT of 5 for survival over 5 years in patients with resting hypoxemia (PaO2 < 60 mmHg on room air).
            • Emerging areas of precision health in COPD with potential for low NNTs in specific circumstances include anti‐interleukin‐5 therapy for eosinophilic COPD, and immunoglobulin replacement therapy for patients with severe immunoglobulin deficiency.

            • 1 University of British Columbia, Vancouver, Canada
            • 2 St Paul's Hospital, Vancouver, Canada


            Correspondence: Don.Sin@hli.ubc.ca
            Competing interests:

            Don Sin has received personal fees for sitting on COPD advisory boards of Sanofi‐Aventis, AstraZeneca and Boehringer Ingelheim, and for speaking engagements from AstraZeneca and Boehringer Ingelheim, outside of the submitted work.

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              Slower increase in life expectancy in Australia than in other high income countries: the contributions of age and cause of death

              Alan D Lopez and Tim Adair
              Med J Aust 2019; 210 (9): . || doi: 10.5694/mja2.50144
              Published online: 20 May 2019

              Abstract

              Objectives: To compare life expectancy at birth in Australia during 1980–2016 with that in other high income countries; to estimate the contributions of age at death and cause of death to differences between Australia and these countries.

              Design, setting, participants: Data on deaths by age, sex, and cause in Australia and 26 other high income countries obtained from the Global Burden of Disease study.

              Main outcome measures: Contributions of age, cause of death, and birth cohort to differences in life expectancy between Australia and other high income countries and to changes in the differences.

              Results: From 1981 to 2003, life expectancy at birth increased rapidly in Australia, both in absolute terms and in comparison with other high income countries. The main contributor to greater increases for males in Australia than in western Europe was lower mortality from ischaemic heart disease; compared with the United States, mortality from ischaemic heart disease, cerebrovascular disease, and transport‐related injuries was lower. Since 2003, life expectancy has increased more slowly for both sexes than in most other high income countries, mainly because declines in mortality from cardiovascular disease and cancer have slowed. Age‐specific mortality for people born since the 1970s is higher in Australia than in most high income countries.

              Conclusions: Recent declines in mortality in Australia have been relatively modest. Together with the high prevalence of obesity and the limited scope for further increasing life expectancy by reducing the prevalence of smoking, this suggests that future life expectancy increases will be smaller than in other high income countries. Improved control of health risk factors will be required if further substantial life expectancy increases in Australia are to be achieved.

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              • Melbourne School of Population and Global Heath, University of Melbourne, Melbourne, VIC


              Correspondence: alan.lopez@unimelb.edu.au
              Acknowledgements: 

              We acknowledge Mohsen Naghavi of the Institute of Health Metrics and Evaluation, University of Washington, for supplying the data analysed in our study.

              Competing interests:

              No relevant disclosures.

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                Scale‐up of hepatitis C treatment in prisons is key to national elimination

                Timothy Papaluca, Margaret E Hellard, Alexander J V Thompson and Andrew R Lloyd
                Med J Aust 2019; 210 (9): . || doi: 10.5694/mja2.50140
                Published online: 20 May 2019

                Prison‐based antiviral treatment for chronic hepatitis C is a critical element of the national elimination goal

                In 2016, it was estimated 227 000 Australians had chronic hepatitis C virus (HCV) infection, with the majority infected through unsafe injecting drug use.1 The advent of direct‐acting antiviral (DAA) therapies for HCV infection, and their subsequent listing on the Pharmaceutical Benefits Scheme in March 2016, means that all Australians with chronic HCV, including prisoners, can access well tolerated, short course, highly curative treatments, regardless of how they acquire their infection or their disease stage. This universal access approach is supported by modelling that shows that increasing treatment uptake among people who inject drugs is an effective public health measure to reduce community prevalence due to the interruption of HCV transmissions.2 These elements underpin Australia's efforts to meet the World Health Organization goal to eliminate HCV as a public health threat by 2030, including key targets of a 90% decline in new infections, a reduction in HCV‐related mortality by 65%, and HCV treatment provision for 80% of those infected.3


                • 1 St Vincent's Hospital, Melbourne, VIC
                • 2 Centre for Population Health, Burnet Institute, Melbourne, VIC
                • 3 Kirby Institute, UNSW, Sydney, NSW


                Correspondence: a.lloyd@unsw.edu.au
                Acknowledgements: 

                The manuscript of this article was prepared on behalf of the National Prisons Hepatitis Network and has been approved by the Network members. Margaret Hellard and Alexander Thompson are supported by National Health and Medical Research Council (NHMRC) Research Fellowships. Andrew Lloyd is supported by an NHMRC Practitioner Fellowship.

                Competing interests:

                Timothy Papaluca has received speaker fees from MSD. Margaret Hellard has received investigator‐initiated support for hepatitis‐related research from Gilead Sciences, AbbVie and GSK. Alexander Thompson has received investigator‐initiated support for hepatitis‐related research from Gilead Sciences, AbbVie and Merck. He is a member of advisory boards for Gilead Sciences, AbbVie, MSD, Bristol‐Myers Squibb and Eisai, and has received speaker fees from Gilead Sciences, AbbVie, MSD and Bristol‐Myers Squibb. Andrew Lloyd has received investigator‐initiated support for prisons hepatitis‐related research from Gilead Sciences and MSD.

                Online responses are no longer available. Please refer to our instructions for authors page for more information.

                  Biology and therapy of multiple myeloma

                  Douglas E Joshua, Christian Bryant, Caroline Dix, John Gibson and Joy Ho
                  Med J Aust 2019; 210 (8): . || doi: 10.5694/mja2.50129
                  Published online: 6 May 2019

                  Summary

                  • Genetic sequencing of the myeloma genome has not revealed a specific disease‐determining genetic alteration.
                  • Multiple disease subclones exist at diagnosis and vary in clinical importance with time and drug sensitivity.
                  • New diagnostic criteria have identified indications for early introduction of therapy.
                  • Autologous stem cell transplantation remains an essential component of therapy in young and fit patients.
                  • The use of continual suppressive (maintenance) therapy has been established as an important component in therapy.
                  • Immune therapies and the harnessing of the innate immune system offer great promise for future treatments.
                  • Since 2005, quality of life, supportive therapies, and survival have dramatically improved over a decade of remarkable progress.
                  • The common manifestations of multiple myeloma, such as bone pain, fatigue and weight loss, may be non‐specific and are often initially ignored or missed by patients and medical practitioners.

                  • Royal Prince Alfred Hospital, Sydney, NSW


                  Competing interests:

                  No relevant disclosures.

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                    Advances in stroke medicine

                    Bruce CV Campbell
                    Med J Aust 2019; 210 (8): . || doi: 10.5694/mja2.50137
                    Published online: 6 May 2019

                    Summary

                    • In recent years, reperfusion therapies such as intravenous thrombolysis and endovascular thrombectomy for ischaemic stroke have dramatically reduced disability and revolutionised stroke management.
                    • Thrombolysis with alteplase is effective when administered to patients with potentially disabling stroke, who are not at high risk of bleeding, within 4.5 hours of the time the patient was last known to be well. Emerging evidence suggests that other thrombolytics such as tenecteplase may be even more effective. Treatment may be possible beyond 4.5 hours in patients selected using brain imaging.
                    • Endovascular thrombectomy (via angiography) effectively reduces risk of death or dependency in patients with large vessel occlusion (internal carotid, proximal middle cerebral and basilar arteries) if applied within 6 hours of the time they were last known to be well.
                    • Endovascular thrombectomy is also beneficial 6–24 hours from the last known well time in selected patients with favourable brain imaging. Thus, some patients with wake‐up stroke are now treatable, and protocols for stroke need to include computed tomography (CT) perfusion scan and CT angiography as routine, in addition to the non‐contrast CT brain scan.
                    • Optimised pre‐hospital and emergency department systems (eg, code stroke response teams, pre‐notification by ambulance, direct transport from triage to CT scanner) are essential to maximise the benefit of these strongly time‐dependent therapies. Telemedicine is increasingly providing specialist guidance for these more complex treatment decisions in rural areas.
                    • Important developments in secondary stroke prevention include the use of direct oral anticoagulants or left atrial appendage occlusion for atrial fibrillation, and endovascular closure of patent foramen ovale.

                    • Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC


                    Correspondence: Bruce.Campbell@mh.org.au
                    Competing interests:

                    Bruce Campbell has received research support from the National Health and Medical Research Council (GNT1043242, GNT1035688), the Royal Australasian College of Physicians, the Royal Melbourne Hospital Foundation, the National Heart Foundation and the Stroke Foundation. He has received unrestricted grant funding for the EXTEND‐IA trial to the Florey Institute of Neuroscience and Mental Health from Medtronic. He co‐chaired the 2017 Australian Stroke Guidelines content working party.

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                      Blindness and acute pancreatitis: Purtscher‐like retinopathy

                      Anthony Yao and Bob Wang
                      Med J Aust 2019; 210 (8): . || doi: 10.5694/mja2.50135
                      Published online: 6 May 2019


                      • Austin Health, Melbourne, VIC


                      Correspondence: anthony.yao@gmail.com
                      Competing interests:

                      No relevant disclosures.

                      • 1. Miguel AIM, Henriques F, Azevedo LFR, et al. Systematic review of Purtscher's and Purtscher‐like retinopathies. Eye 2013; 27: 1–13.
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