Topics

Abstract

Introduction: The evidence‐based national clinical practice guidelines for the management of cutaneous melanoma published in 2008 are currently being updated. This article summarises the findings from multiple chapters of the guidelines on different methods of melanoma detection and of monitoring the skin for patients at high risk of melanoma. Early detection of melanoma is critical, as thinner tumours are associated with enhanced survival; therefore, strategies to improve early detection are important to reduce melanoma‐related mortality.

Main recommendations:

Clinicians who perform skin examinations for the purpose of detecting skin cancer should be trained in and use dermoscopy.
The use of short term sequential digital dermoscopy imaging to detect melanomas that lack dermoscopic features of melanoma is recommended to assess individual melanocytic lesions of concern.
The use of long term sequential digital dermoscopy imaging to detect melanomas that lack dermoscopic features of melanoma is recommended to assess individual or multiple melanocytic lesions for routine surveillance of high risk patients.
The use of total body photography should be considered in managing patients at increased risk for melanoma, particularly those with high naevus counts and dysplastic naevi.
There is insufficient evidence to recommend the routine use of automated instruments for the clinical diagnosis of primary melanoma.

Management overview: Determining the relative indications for each diagnostic method and how each method should be introduced into the surveillance of a patient requires careful consideration and an individualised approach.

1 Victorian Melanoma Service, Alfred Hospital, Melbourne, VIC
2 Armadale Dermatology, Melbourne, VIC
3 Melanoma Institute Australia, Sydney, NSW
4 University of Sydney, Sydney, NSW
5 Royal Prince Alfred Hospital, Sydney, NSW
6 Sydney Melanoma Diagnostic Centre, University of Sydney, Sydney, NSW
7 Victorian Melanoma Service, Alfred Health, Melbourne, VIC
8 Glenferrie Dermatology, Melbourne, VIC
9 Norwest Skin Cancer Centre, Sydney, NSW
10 Melanoma Patients Australia, Brisbane, QLD
11 MelanomaWA, Perth, WA
12 Dermatology Research Centre, Diamantina Institute, University of Queensland, Brisbane, QLD
13 Princess Alexandra Hospital, Brisbane, QLD

Correspondence: nikki.adler@monash.edu

Acknowledgements:

The development of the new Australian clinical practice guidelines for the diagnosis and management of melanoma was funded by Cancer Council Australia and the Melanoma Institute Australia, with additional support from the Skin Cancer College Australasia and the Australasian College of Dermatologists. Nikki Adler is supported by a Research Training Program stipend scholarship, Monash University. H Peter Soyer has an NHMRC Practitioner Fellowship. John Thompson is supported by the Melanoma Foundation at the University of Sydney.

Competing interests:

No relevant disclosures.

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Reflections
Medical history

Forty years of “Waltzing Matilda”: the history of the multichannel cochlear implant

Joyce PK Ho, Hannah North and Narinder P Singh

Med J Aust 2018; 209 (11): . || doi: 10.5694/mja18.00365
Published online: 3 December 2018

Topics

Otorhinolaryngologic diseases

The fascinating history of the multichannel cochlear implant and its inventor, Professor Graeme Clark

A cochlear implant is a surgically implanted device for converting sounds into an electrical current that directly stimulates the cochlear nerve.1 It consists of external (microphone, speech processor, transmitter) and internal components (receiver/stimulator, electrode array in the cochlea) and can be implanted in both children and adults.

1 Westmead Hospital, Sydney, NSW
2 Westmead Clinical School, University of Sydney, Sydney, NSW
3 Ear Nose & Throat Sydney, Sydney, NSW

Correspondence: joycepuikiu.ho@health.nsw.gov.au

Acknowledgements:

All images provided courtesy of Cochlear Limited.

Competing interests:

No relevant disclosures.

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Perspective

The MJA–Lancet Countdown on health and climate change: Australian policy inaction threatens lives

Ying Zhang, Paul J Beggs, Hilary Bambrick, Helen L Berry, Martina K Linnenluecke, Stefan Trueck, Robyn Alders, Peng Bi, Sinead M Boylan, Donna Green, Yuming Guo, Ivan C Hanigan, Elizabeth G Hanna, Arunima Malik, Geoffrey G Morgan, Mark Stevenson, Shilu Tong, Nick Watts and Anthony G Capon

Med J Aust 2018; 209 (11): . || doi: 10.5694/mja18.00789
Published online: 29 November 2018

Topics

Environment and public health

Mental disorders

Health services administration

Summary

Climate plays an important role in human health and it is well established that climate change can have very significant impacts in this regard. In partnership with The Lancet and the MJA, we present the inaugural Australian Countdown assessment of progress on climate change and health.
This comprehensive assessment examines 41 indicators across five broad sections: climate change impacts, exposures and vulnerability; adaptation, planning and resilience for health; mitigation actions and health co-benefits; economics and finance; and public and political engagement.
These indicators and the methods used for each are largely consistent with those of the Lancet Countdown global assessment published in October 2017, but with an Australian focus. Significant developments include the addition of a new indicator on mental health.
Overall, we find that Australia is vulnerable to the impacts of climate change on health, and that policy inaction in this regard threatens Australian lives. In a number of respects, Australia has gone backwards and now lags behind other high income countries such as Germany and the United Kingdom. Examples include the persistence of a very high carbon-intensive energy system in Australia, and its slow transition to renewables and low carbon electricity generation. However, we also find some examples of good progress, such as heatwave response planning.
Given the overall poor state of progress on climate change and health in Australia, this country now has an enormous opportunity to take action and protect human health and lives. Australia has the technical knowhow and intellect to do this, and our annual updates of this assessment will track Australia’s engagement with and progress on this vitally important issue.

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1 School of Public Health, University of Sydney, Sydney, NSW
2 Department of Environmental Sciences, Macquarie University, Sydney, NSW
3 School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD
4 Department of Applied Finance, Macquarie University, Sydney, NSW
5 International Rural Poultry Centre, Kyeema Foundation, Brisbane, QLD
6 Centre for Global Health Security, Chatham House, London, UK
7 School of Public Health, University of Adelaide, Adelaide, SA
8 Climate Change Research Centre, ARC Centre of Excellence for Climate Extremes, University of New South Wales, Sydney, NSW
9 Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC
10 University Centre for Rural Health, University of Sydney, Sydney, NSW
11 Climate Change Institute, Australian National University, Canberra, ACT
12 School of Physics, University of Sydney, Sydney, NSW
13 University Centre for Rural Health, University of Sydney, Lismore, NSW
14 Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC
15 Department of Clinical Epidemiology and Biostatistics, Shanghai Jiao Tong University, Shanghai, China
16 Institute of Environment and Population Health, Anhui Medical University, Hefei, China
17 Institute of Global Health, University College London, London, UK

Correspondence: ying.zhang@sydney.edu.au

Acknowledgements:

We thank Dr Elizabeth Ebert (Australian Bureau of Meteorology) for contributing indicator 2.4 (Climate information services for health). We also thank Dr Luke Knibbs (University of Queensland) who provided assistance with the PM monitor data for indicator 3.5.1 (Exposure to air pollution in cities). Indicator 3.9 (Health care sector emissions) builds on Malik et al ( 2018; 2: e27–e35) and we would like to acknowledge the co-authors of that publication: Prof Manfred Lenzen, Dr Forbes McGain and Scott McAlister. We would also like to acknowledge Fabiola Barba Ponce (Macquarie University).

Competing interests:

Anthony Capon directs the human health and social impacts research node of the NSW Adaptation Research Hub.

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Editorials

Reducing cardiovascular risk in people with diabetes and kidney disease

Brendon L Neuen and Vlado Perkovic

Med J Aust 2018; 209 (10): . || doi: 10.5694/mja18.00929
Published online: 19 November 2018

Topics

Endocrine system diseases

Urologic diseases

Cardiovascular diseases

General medicine

We need to move beyond managing end organ complications to reducing cardio-renal risk across the spectrum of kidney function

Type 2 diabetes mellitus is one of the greatest challenges facing the Australian health care system. The number of Australians living with diabetes has tripled over the past 25 years, and by 2025 it is expected that 3 million adults will have been diagnosed with the disease, one of the most rapid rises for any chronic condition in Australia.1

The George Institute for Global Health, Sydney, NSW

Correspondence: VPerkovic@georgeinstitute.org.au

Acknowledgements:

Brendon Neuen is funded by a John Chalmers PhD Scholarship from the George Institute for Global Health and a University Postgraduate Award from UNSW Sydney. Vlado Perkovic receives research support from the National Health and Medical Research Council (Senior Research Fellowship and Program Grant).

Competing interests:

The George Institute for Global Health provides contract research services to Janssen for trials of sodium/glucose cotransporter 2 (SGLT2) inhibitors. Brendon Neuen receives travel support from Janssen. Vlado Perkovic is the chair of a steering committee for a renal outcome study of an SGLT2 inhibitor (canagliflozin), serves on steering committees for AbbVie, Boehringer Ingelheim, GlaxoSmithKline, Janssen and Pfizer, and serves on advisory boards or speaks at scientific meetings for AbbVie, Astellas, AstraZeneca, Bayer, Baxter, Bristol-Myers Squibb, Boehringer Ingelheim, Durect, Eli Lilly, Gilead, GlaxoSmithKline, Janssen, Merck, Novartis, Novo Nordisk, Pfizer, Pharmalink, Relypsa, Roche, Sanofi, Servier and Vitae; all honoraria for these activities are paid to the George Institute for Global Health. 

1. Baker IDI Heart and Diabetes Institute, Diabetes Australia, Juvenile Diabetes Research Foundation. Diabetes: the silent pandemic and its impact on Australia. 2012. https://baker.edu.au/-/media/documents/impact/diabetes-the-silent-pandemic.ashx?la=en (viewed Sept 2018).
2. Thomas MC, Cooper ME, Zimmet P. Changing epidemiology of type 2 diabetes mellitus and associated chronic kidney disease. Nat Rev Nephrol 2016; 12: 73-81.
3. Kidney Health Australia. The economic impact of end-stage kidney disease in Australia: projections to 2020. 2010. https://kidney.org.au/cms_uploads/docs/kha-economic-impact-of-eskd-in-australia-projections-2020.pdf (viewed Sept 2018).
4. Lim WH, Johnson DW, Hawley C, et al. Type 2 diabetes in patients with end-stage kidney disease: influence on cardiovascular disease-related mortality risk. Med J Aust 2018; 209: 440-446.
5. Lascar N, Brown J, Pattison H, et al. Type 2 diabetes in adolescents and young adults. Lancet Diabetes Endocrinol 2018; 6: 69-80.
6. Wanner C, Tonelli M. KDIGO clinical practice guideline for lipid management in CKD: summary of recommendation statements and clinical approach to the patient. Kidney Int 2014; 85: 1303-1309.
7. Heerspink HJL, Ninomiya T, Zoungas S, et al. Effect of lowering blood pressure on cardiovascular events and mortality in patients on dialysis: a systematic review and meta-analysis of randomised controlled trials. Lancet 2009; 373: 1009-1015.
8. Palmer SC, Di Micco L, Razavian M, et al. Effects of antiplatelet therapy on mortality and cardiovascular and bleeding outcomes in persons with chronic kidney disease: a systematic review and meta-analysis. Ann Intern Med 2012; 156: 445-459.
9. O’Lone E, Viecelli AK, Craig JC, et al. Cardiovascular outcomes reported in hemodialysis trials. J Am Coll Cardiol 2018; 71: 2802-2810.
10. Tong A, Manns B, Hemmelgarn B, et al. Establishing core outcome domains in hemodialysis: report of the Standardized Outcomes in Nephrology–Hemodialysis (SONG-HD) consensus workshop. Am J Kidney Dis 2017; 69: 97-107.
11. American Diabetes Association. Pharmacologic approaches to glycemic treatment: standards of medical care in diabetes — 2018. Diabetes Care 2018; 41: S73-S85.
12. Diabetes Canada Clinical Practice Guidelines Expert Committee; Lipscombe L, Booth G, Butalia S, et al. Pharmacologic glycemic management of type 2 diabetes in adults. Can J Diabetes 2018; 42: S88-S103.

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Editorials

Deprescribing proton pump inhibitors: why, when and how

Peter Bytzer

Med J Aust 2018; 209 (10): . || doi: 10.5694/mja18.00674
Published online: 12 November 2018

Topics

Pharmaceutical preparations

Digestive system diseases

The focus should primarily be on avoiding unnecessary long term prescribing of PPIs

For more than 25 years, proton pump inhibitors (PPIs) have been the mainstay of therapy for acid-related disorders, particularly peptic ulcer disease and gastro-oesophageal reflux disease (GORD). In recent decades, prescribing of PPIs has increased considerably around the world. According to a recent national drug utilisation study, prescribing of PPIs increased fourfold in Denmark between 2002 and 2014, with the increase particularly marked among older patients; 7% of all adults and 14% of adults over 60 were covered by PPI prescriptions.1 The increased prescribing of PPIs is driven primarily by the accumulation of existing users rather than by new users; inappropriate prescribing and long term use, rather than genuine clinical need for ulcer prophylaxis, appear to underlie the high prevalence of PPI prescribing.2 Changes to public subsidisation of PPI costs and interventions for improving adherence to guidelines and promoting the rational use of PPIs have not had a substantial influence on prescribing patterns.

University of Copenhagen, Køge, Denmark

Correspondence: pmby@regionsjaelland.dk

Competing interests:

No relevant disclosures.

1. Pottegård A, Broe A, Hallas J, et al. Use of proton-pump inhibitors among adults: a Danish nationwide drug utilization study. Therap Adv Gastroenterol 2016; 9: 671-678.
2. Batuwitage BT, Kingham JG, Morgan NE, Bartlett RL. Inappropriate prescribing of proton pump inhibitors in primary care. Postgrad Med J 2007; 83: 66-68.
3. Vaezi, MF, Yang YX, Howden CW. Complications of proton pump inhibitor therapy. Gastroenterology 2017; 153: 35-48.
4. Reimer C. Safety of long-term PPI therapy. Best Pract Res Clin Gastroenterol 2013; 27: 443-454.
5. Lødrup AB, Reimer C, Bytzer P. Systematic review: symptoms of rebound acid hypersecretion following proton pump inhibitor treatment. Scand J Gastroenterol 2013; 48: 515-522.
6. Haastrup P, Paulsen MS, Begtrup LM, et al. Strategies for discontinuation of proton pump inhibitors: a systematic review. Fam Pract 2014; 31: 625-630.
7. Reimer C, Bytzer P. Discontinuation of long-term proton pump inhibitor therapy in primary care patients: a randomized placebo-controlled trial in patients with symptom relapse. Eur J Gastroenterol Hepatol 2010; 22: 1182-1188.
8. Murie J, Allen J, Simmonds R, de Wet C. Glad you brought it up: a patient-centred programme to reduce proton-pump inhibitor prescribing in general medical practice. Qual Prim Care 2012; 20: 141-148.
9. Björnsson E, Abrahamsson H, Simrén M, et al. Discontinuation of proton pump inhibitors in patients on long-term therapy: a double-blind, placebo-controlled trial. Aliment Pharmacol Ther 2006; 24: 945-954.
10. Inadomi, JM, Jamal R, Murata GH, et al. Step-down management of gastroesophageal reflux disease. Gastroenterology 2001; 121: 1095-1100.
11. National Prescribing Service. Reviewing PPIs for GORD. June 2018. https://cdn0.scrvt.com/08ab3606b0b7a8ea53fd0b40b1c44f86/c052d66150fd152a/df9dd3c72fab/Reviewing-PPIs-for-GORD-algorithm-June-2018.pdf (viewed July 2018).
12. Bytzer P. Goals of therapy and guidelines for treatment success in symptomatic gastroesophageal reflux disease patients. Am J Gastroenterol 2003; 98(3 Suppl): S31-S39.

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Research letter

Gluten in “gluten-free” manufactured foods in Australia: a cross-sectional study

Emma P Halmos, Dean Clarke, Catherine Pizzey and Jason A Tye-Din

Med J Aust 2018; 209 (10): . || doi: 10.5694/mja18.00457
Published online: 12 November 2018

Topics

Digestive system diseases

Environment and public health

Patients with coeliac disease must strictly adhere to a gluten-free diet. Two potential sources of inadvertent gluten exposure are meals provided when dining out and manufactured “gluten-free” foods. A recent study1 found that 9% of gluten-free food samples from Melbourne food businesses failed to meet the national standard of “no detectable gluten”2. As no data on gluten levels in manufactured “gluten-free” foods in Australia have been published, we measured the gluten content of a broad sample of these foods.

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1 Royal Melbourne Hospital, Melbourne, VIC
2 Monash University Central Clinical School, Melbourne, VIC
3 National Measurement Institute, Melbourne, VIC
4 Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC

Correspondence: tyedin@wehi.edu.au

Acknowledgements:

Emma Halmos was funded by a research grant from Coeliac Australia. We thank the Nielsen Company for their data on the most commonly purchased foods; and Martina Koeberl, Jasmit Khangurha and Rasika Wijerathne (National Measurement Institute) for conducting the food analyses.

Competing interests:

Jason Tye-Din is a co-inventor on patents pertaining to applications of gluten peptides in therapeutics, diagnostics, and non-toxic gluten; he is a shareholder in Nexpep and a consultant to ImmusanT (USA).

1. Halmos EP, Di Bella CA, Webster R, et al. Gluten in “gluten-free” food from food outlets in Melbourne: a cross-sectional study. Med J Aust 2018; 209: 42-43. <MJA full text>
2. Food Standards Australia New Zealand. Standard 1.2.7. Nutrition, health and related claims. Nov 2017. https://www.legislation.gov.au/Details/F2017C01048 (viewed Apr 2018).
3. Forbes GM, Dods K. Gluten content of imported gluten-free foods: national and international implications. Med J Aust 2016; 205: 316. <MJA full text>
4. Catassi C, Fabiani E, Iacono G, et al. A prospective, double-blind, placebo-controlled trial to establish a safe gluten threshold for patients with celiac disease. Am J Clin Nutr 2007; 85: 160-166.
5. Zurzolo GA, Peters RL, Koplin JJ, et al. The practice and perception of precautionary allergen labelling by the Australasian food manufacturing industry. Clin Exp Allergy 2017; 47: 961-968.

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Narrative review

Preventing ovarian failure associated with chemotherapy

Wanyuan Cui, Catharyn Stern, Martha Hickey, Fiona Goldblatt, Antoinette Anazodo, William S Stevenson and Kelly-Anne Phillips

Med J Aust 2018; 209 (9): . || doi: 10.5694/mja18.00190
Published online: 5 November 2018

Topics

Women's health

Neoplasms

General medicine

Skin and connective tissue diseases

Summary

Alkylating chemotherapy is often used to treat pre-menopausal women for various malignancies and autoimmune diseases. Chemotherapy-associated ovarian failure is a potential consequence of this treatment which can cause infertility, and increases the risk of other long term adverse health sequelae.
Randomised trials, predominantly of women undergoing alkylating chemotherapy for breast cancer, have shown evidence for the efficacy of gonadotropin-releasing hormone agonists (GnRHa) in preventing chemotherapy-associated ovarian failure.
The European St Gallen and United States National Comprehensive Cancer Network guidelines recommend the use of concurrent GnRHa to reduce the risk of ovarian failure for pre-menopausal women undergoing chemotherapy for breast cancer.
The GnRHa goserelin, a monthly 3.6 mg depot subcutaneous injection, has recently been listed on the Australian Pharmaceutical Benefits Scheme to reduce risk of ovarian failure for pre-menopausal women receiving alkylating therapies for malignancy or autoimmune disease.
The first dose of goserelin should ideally be administered at least 1 week before commencement of alkylating treatment and continued 4-weekly during chemotherapy.
Concurrent goserelin use should now be considered for all pre-menopausal women due to commence alkylating chemotherapy (except those with incurable cancer), regardless of their childbearing status, in an effort to preserve their ovarian function. For women who have not completed childbearing, consideration of other fertility preservation options, such as cryopreservation of embryos or oocytes, is also important.

1 Peter MacCallum Cancer Centre, Melbourne, VIC
2 University of Melbourne, Melbourne, VIC
3 Royal Women's Hospital, Melbourne, VIC
4 Flinders Medical Centre and Flinders University, Adelaide, SA
5 Kids Cancer Centre, Sydney Children's Hospital, Randwick, Sydney, NSW
6 Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Sydney, NSW
7 Royal North Shore Hospital, Sydney, NSW
8 Northern Clinical School, University of Sydney, Sydney, NSW

Correspondence: kelly.phillips@petermac.org

Acknowledgements:

Kelly-Anne Phillips is a National Breast Cancer Foundation Practitioner Fellow. Martha Hickey is a National Health and Medical Research Council Practitioner Fellow. Antoinette Anazodo’s research is supported by Kids Cancer Alliance, Cancer Institute NSW Translational Cancer Research Centre (15/TRC/1-04), and CanTeen funding from the federal Department of Health.

Competing interests:

No relevant disclosures.

1. Australian Government Cancer Australia. Lymphoma statistics. https://lymphoma.canceraustralia.gov.au/statistics (viewed Jan 2018).
2. Australian Government Cancer Australia. Breast cancer statistics. https://breast-cancer.canceraustralia.gov.au/statistics (viewed Apr 2018).
3. Colvin M. Alkylating agents. In: Kufe DW, Pollock RE, Weichselbaum RR, et al, editors. Holland-Frei Cancer Medicine. 6th ed. Hamilton, ON: BC Decker, 2003.
4. Sklar CA, Mertens AC, Mitby P, et al. Premature menopause in survivors of childhood cancer: a report from the childhood cancer survivor study. J Natl Cancer Inst 2006; 98: 890-896.
5. Logan S, Perz J, Ussher JM, et al. A systematic review of patient oncofertility support needs in reproductive cancer patients aged 14 to 45 years of age. Psychooncology 2017; 27: 401-409.
6. Howard-Anderson J, Ganz PA, Bower JE, Stanton AL. Quality of life, fertility concerns, and behavioural health outcomes in younger breast cancer survivors: a systematic review. J Natl Cancer Inst 2012; 104: 386-405.
7. Jackisch C, Harbeck N, Huober J, et al. 14th St Gallen International Breast Cancer Conference 2015: Evidence, Controversies, Consensus – Primary Therapy of Early Breast Cancer: opinions expressed by German experts. Breast Care 2015; 10: 211-219.
8. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology. Fort Washington, PA: NCCN, 2017. https://www.nccn.org/professionals/physician_gls/pdf/aya.pdf (viewed Oct 2017).
9. Australian Government Department of Health. The Pharmaceutical Benefits Scheme. Goserelin. www.pbs.gov.au/medicine/item/1454M www.pbs.gov.au/medicine/item/1454M (viewed Dec 2017).
10. Demeestere I, Brice P, Peccatori FA, et al. Gonadotropin-releasing hormone agonist for the prevention of chemotherapy-induced ovarian failure in patients with lymphoma: 1-year follow-up of a prospective randomized trial. J Clin Oncol 2013; 31: 903-909.
11. Mar Fan HG, Houede-Tchen N, Chemerynsky I, et al. Menopausal symptoms in women undergoing chemotherapy-induced and natural menopause: a prospective controlled study. Ann Oncol 2010; 21: 983-987.
12. Shapiro CL, Manola J, Leboff M. Ovarian failure after adjuvant chemotherapy is associated with rapid bone loss in women with early-stage breast cancer. J Clin Oncol 2001; 19: 3306-3311.
13. Ryan J, Scali J, Carriere I, et al. Impact of a premature menopause on cognitive function in later life. BJOG 2014; 121: 1729-1739.
14. Rocca WA, Grossardt BR, De Andrade M, et al. Survival patterns after oophorectomy in premenopausal women: a population based cohort study. Lancet Oncol 2006; 7: 821-828.
15. Roness H, Kalich-Philosoph L, Meirow D. Prevention of chemotherapy induced ovarian damage: possible roles for hormonal and non hormonal attenuating agents. Hum Reprod Update 2014; 20: 759-774.
16. Millar RP, Lu Z, Pawson AJ, et al. Gonadotropin-Releasing Hormone Receptors. Endocr Rev 2004; 25: 235-275.
17. West CP, Baird DT. Suppression of ovarian activity by zoladex depot (ICI 118630), a long acting luteinizing hormone releasing hormone agonist analogue. Clin Endocrinol 1987; 26: 213-220.
18. Kerr JB, Hutt KJ, Michalak EM, et al. DNA damage-induced primordial follicle oocyte apoptosis and loss of fertility require TAp63-mediated induction of Puma and Noxa. Mol Cell 2012; 48: 343-352.
19. Ataya K, Rao LV, Lawrence E, Kimmel R. Luteinizing hormone- releasing hormone agonist inhibits cyclophosphamide induced ovarian follicular depletion in Rhesus monkeys. Biol Reprod 1995; 52: 365-372.
20. Munhoz RR, Pereira AA, Sasse AD, et al. Gonadotropin-releasing hormone agonists for ovarian function preservation in premenopausal women undergoing chemotherapy for early stage breast cancer: a systematic review and meta-analysis. JAMA Oncol 2016; 2: 65-73.
21. Moore HC, Unger JM, Phillips K, et al. Goserelin for ovarian protection during breast-cancer adjuvant chemotherapy. N Engl J Med 2015; 372: 923-932.
22. Del Mastro L, Boni L, Michelotti A, et al. Effect of the gonadotropin-releasing hormone analogue triptorelin on the occurrence of chemotherapy-induced early menopause in premenopausal women with breast cancer: a randomized trial. JAMA 2011; 306: 269-276.
23. Lambertini M, Boni L, Michelotti A, et al. Ovarian suppression with triptorelin during adjuvant breast cancer chemotherapy and long-term ovarian function, pregnancies, and disease-free survival: a randomized clinical trial. JAMA 2015; 314: 2632-2640.
24. Leonard RC, Adamson DJ, Bertelli G, et al. GnRH agonist for protection against ovarian toxicity during chemotherapy for early breast cancer: the Anglo Celtic Group OPTION trial. Ann Oncol 2017; 28: 1811-1816.
25. Garrido-Oyarzun MF, Castelo-Branco C. Controversies over the use of GnRH agonists for reduction of chemotherapy-induced gonadotoxicity. Climacteric 2016; 19: 522-525.
26. Giuseppe L, Attilio G, Edoardo DN, Loredana G, Cristina L, Vincenzo L. Ovarian function after cancer treatment in young women affected by Hodgkin disease (HD). Hematology 2007; 12: 141-147.
27. Waxman JH, Ahmed R, Smith D, et al. Failure to preserve fertility in patients with Hodgkin’s disease. Cancer Chemother Pharmacol 1987; 19: 159-162.
28. Demeestere I, Brice P, Peccatori FA, et al. No evidence for the benefit of gonadotropin-releasing hormone agonist in preserving ovarian function and fertility in lymphoma survivors treated with chemotherapy: Final long-term report of a prospective randomized trial. J Clin Oncol 2016; 34: 2568-2574.
29. Lambertini M, Falcone T, Unger JM, et al. Correspondence: Debated role of ovarian protection with gonadotrophin-releasing hormone agonists during chemotherapy for preservation of ovarian function and fertility in women with cancer. J Clin Oncol 2017; 35: 804-805.
30. Zhang Y, Xiao Z, Wang Y, et al. Gonadotropin-releasing hormone for preservation of ovarian function during chemotherapy in lymphoma patients of reproductive age: a summary based on 434 patients. PLoS One 2013; 8: e80444.
31. Salooja N, Szydlo RM, Socie G, et al. Pregnancy outcomes after peripheral blood or bone marrow transplantation: a retrospective survey, Lancet 2001; 358: 271-276.
32. Anazodo AC, Stern C, McLachlan RI, et al. A study protocol for the Australasian oncofertility registry: monitoring referral patterns and the uptake, quality and complications of fertility preservation strategies in Australia and New Zealand. J Adolesc Young Adult Oncol 2016; 5: 215-225.
33. Boumpas DT, Austin H, Vaughan EM, et al. Risk for sustained amenorrhea in patients with systemic lupus erythematosus receiving intermittent pulse cyclophosphamide therapy. Ann Intern Med 1993; 119: 366-369.
34. Blumenfeld Z. Preservation of fertility and ovarian function and minimising gonadotoxicity in young women with systemic lupus erythematosus treated by chemotherapy. Lupus 2000; 9: 401-405.
35. Clowse M, Behera M, Anders CK, et al. Ovarian preservation by GnRH agonists during chemotherapy: a metaanalysis. J Womens Health 2009; 18: 311-319.
36. Somers EC, Marder W, Christman GM, et al. Use of a gonadotropin-releasing hormone analog for protection against premature ovarian failure during cyclophosphamide therapy in women with severe lupus. Arthritis Rheum 2005; 52: 2261-2767.
37. Goldhirsch A, Gelber RD, Castiglione M. The magnitude of endocrine effects of adjuvant chemotherapy for premenopausal breast cancer patients. Ann Oncol 1990; 1: 183-188.
38. Katsifis GE, Tzioufas AG. Ovarian failure in systemic lupus erythematosus patients treated with pulsed intravenous cyclophosphamide. Lupus 2004; 13: 673-678.
39. United States Food and Drug Administration. Zoladex (goserelin acetate implant) 3.6 mg. https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/019726s059,020578s037lbl.pdf (viewed Sept 2018).

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Guideline summary

Updated clinical practice guidelines on pregnancy care

Caroline SE Homer, Jeremy Oats, Philippa Middleton, Jenny Ramson and Samantha Diplock

Med J Aust 2018; 209 (9): . || doi: 10.5694/mja18.00286
Published online: 5 November 2018

Topics

Women's health

Digestive system diseases

Nutritional and metabolic diseases

Abstract

Introduction: The clinical practice guidelines on pregnancy care have been developed to provide reliable and standardised guidance for health professionals providing antenatal care in Australia. They were originally released as the Clinical Practice Guidelines: Antenatal Care in two separate editions (modules 1 and 2) in 2012 and 2014. These modules have now been combined and updated to form a single set of consolidated guidelines that were publicly released in February 2018 as the Clinical Practice Guidelines: Pregnancy Care. Eleven topics have been updated and new guidance on substance use in pregnancy has been added.

Main recommendations: The updated guidelines include the following key changes to practice:

recommend routine testing for hepatitis C at the first antenatal visit;
recommend against routine testing for vitamin D status in the absence of a specific indication;
recommend discussing weight change, diet and physical activity with all pregnant women; and
recommend offering pregnant women the opportunity to be weighed at every antenatal visit and encouraging women to self-monitor weight gain.

Changes in management as a result of the guidelines: The guidelines will enable pregnant women diagnosed with hepatitis C to be identified and thus avoid invasive procedures that increase the risk of mother-to-baby transmission. Women can be treated postpartum, reducing the risk of liver disease and removing the risk of perinatal infection for subsequent pregnancies. Routine testing of all pregnant women for vitamin D status and subsequent vitamin D supplementation is not supported by evidence and should cease as the benefits and harms of vitamin D supplementation remain unclear. The recommendation for health professionals to provide advice to pregnant women about weight, diet and physical activity, and the opportunity to be weighed will help women to make changes leading to better health outcomes for themselves and their babies.

1 Centre for Midwifery, Child and Family Health, UTS Sydney, Sydney, NSW
2 Burnet Institute, Melbourne, VIC
3 Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC
4 Robinson Research Institute, University of Adelaide, Adelaide, SA
5 Ampersand Health Science Writing, Tanja, NSW
6 Department of Health, Canberra, ACT

Correspondence: caroline.homer@uts.edu.au

Acknowledgements:

The review of the guidelines was jointly funded by the Australian Government and the states and territories. The review was project managed by the Australian Government Department of Health. The authors acknowledge the engagement and support of the Australian College of Midwives, the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives, the Royal Australian College of General Practitioners and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. EWG members who have supported the review of the guidelines: Professor Jeremy Oats, University of Melbourne (co-chair); Professor Caroline Homer, University of Technology Sydney and the Australian College of Midwives (co-chair); Associate Professor Philippa Middleton, South Australian Health and Medical Research Institute Adelaide; Dr Martin Byrne, Royal Australian College of General Practitioners; Ann Catchlove, consumer representative; Lisa Clements, migrant and refugee women representative; Dr Anthony Hobbs, Commonwealth Deputy Chief Medical Officer; Tracy Martin, WA Health; Professor Sue McDonald, La Trobe University; Dr Sarah Jane McEwan, Western Australian Country Hedland Service; Professor Michael Permezel, Royal Australian College of Obstetricians and Gynaecologists; Adjunct Professor Debra Thoms, Commonwealth Chief Nursing and Midwifery Officer; Louis Young, Department of Health (Secretariat); Samantha Diplock, Department of Health (Secretariat); Anita Soar, Department of Health (Secretariat); and Jenny Ramson, Ampersand Health Science Writing (technical writer).

Competing interests:

No relevant disclosures.

1. World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. Geneva: WHO, 2016. http://apps.who.int/iris/bitstream/handle/10665/250796/9789241549912-eng.pdf?sequence=1 (viewed Jan 2017).
2. Australian Institute of Health and Welfare. Australia’s mothers and babies 2016—in brief. (AIHW Cat. No. PER 97; Perinatal Statistics Series No. 34). Canberra: AIHW, 2018. https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies-2016-in-brief/contents/table-of-contents (viewed Aug 2018).
3. Australian Government Department of Health. Clinical practice guidelines: pregnancy care. Canberra: Department of Health, 2018. www.health.gov.au/pregnancycareguidelines (viewed June 2018).
4. Australian Health Ministers’ Advisory Council. Clinical practice guidelines: antenatal care — module 1. Canberra: Department of Health and Ageing, 2012.
5. Australian Health Ministers’ Advisory Council. Clinical practice guidelines: antenatal care — module 2. Canberra: Commonwealth of Australia, 2014.
6. Guyatt G, Oxman A, Vist G, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008; 336: 924-926.
7. Guyatt G, Oxman A, Kunz R, et al. Going from evidence to recommendations. BMJ 2008; 336(7652): 1049-1051.
8. Australian Government Department of Health. Hep C medicines: the facts. June 2017. http://www.pbs.gov.au/publication/factsheets/hep-c/files/hepc-factsheet-consumers-what-is-hep-c.pdf (viewed Mar 2018).
9. Australian Bureau of Statistics. 4364.0.55.006 - Australian Health Survey: biomedical results for nutrients, 2011-12. Canberra: ABS, 2014. http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4364.0.55.006Chapter2002011-12 (viewed June 2016).
10. McDonald S, Zhen H, Sohail M, Joseph B. Overweight and obesity in mothers and risk of preterm birth and low birth weight infants: systematic review and meta-analyses BMJ 2010; 341: c3428.
11. Magro-Malosso E, Saccone G, Di Mascio D, et al. Exercise during pregnancy and risk of preterm birth in overweight and obese women: a systematic review and meta-analysis of randomized controlled trials. Acta Obstet Gynecol Scand 2017; 96: 263-273.

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Editorials

Pre-conception care: an important yet underutilised preventive care strategy

Deborah J Bateson and Kirsten I Black

Med J Aust 2018; 209 (9): . || doi: 10.5694/mja18.00769
Published online: 5 November 2018

Topics

Women's health

Environment and public health

Parental health prior to conception is increasingly recognised as being important for the health of future generations

Pre-conception care is the provision of health recommendations to women of reproductive age with the goal of improving short and long term health outcomes for both the mothers and their children. It includes an assessment of medical conditions, vaccination status, and lifestyle factors.1 While pre-conception care will benefit any woman contemplating pregnancy, it is particularly important for women with medical conditions such as diabetes and obesity. Nevertheless, it is often underutilised.2 In this article, we describe strategies for overcoming challenges to providing pre-conception care and provide guidance for time-poor clinicians.

1 Family Planning New South Wales, Sydney, NSW
2 University of Sydney, Sydney, NSW
3 Royal Prince Alfred Hospital, Sydney, NSW

Correspondence: deborahb@fpnsw.org.au

Competing interests:

No relevant disclosures.

1. Royal Australian College of General Practitioners. Preventive activities prior to pregnancy. In: Guidelines for preventive activities in general practice. 9th edition. Melbourne: RACGP, 2017. https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/red-book/preventive-activities-prior-to-pregnancy (viewed Sept 2018).
2. McElduff A, Ross GP, Lagstrom JA, et al. Pregestational diabetes and pregnancy: an Australian experience. Diabetes Care 2005; 28: 1260-1261.
3. Rassi A, Wattimena J, Black K. Pregnancy intention in an urban Australian antenatal population. Aust N Z J Public Health 2013; 37: 568-573.
4. Mazza D, Chapman A, Michie S. Barriers to the implementation of preconception care guidelines as perceived by general practitioners: a qualitative study. BMC Health Serv Res 2013; 13: 36.
5. Bellanca HK, Hunter MS. ONE KEY QUESTION: preventive reproductive health is part of high quality primary care. Contraception 2013; 88: 3-6.
6. Tommy’s. Planning for pregnancy [website]. 2018. https://www.tommys.org/pregnancy-information/planning-pregnancy/planning-for-pregnancy-tool (viewed Sept 2018).
7. De-Regil LM, Peña-Rosas JP, Férnandez-Gaxiola AC, Rayco-Solon P. Effects and safety of periconceptional oral folate supplementation for preventing birth defects. Cochrane Database Syst Rev 2015; (12): CD007950.
8. Harding KB, Peña-Rosas JP, Webster AC, et al. Iodine supplementation for women during the preconception, pregnancy and postpartum period. Cochrane Database Syst Rev 2017; (3): CD011761.
9. Schummers L, Hutcheon JA, Bodnar LM, et al. Risk of adverse pregnancy outcomes by prepregnancy body mass index: a population-based study to inform prepregnancy weight loss counseling. Obstet Gynecol 2015; 125: 133-143.
10. Boggess KA, Edelstein BL. Oral health in women during preconception and pregnancy: implications for birth outcomes and infant oral health. Matern Child Health J 2006; 10: 169-174.
11. Blatt K, Moore E, Chen A, et al. Association of reported trimester-specific smoking cessation with fetal growth restriction. Obstet Gynecol 2015; 125: 1452-1459.
12. Lassi ZS, Imam AM, Dean SV, Bhutta ZA. Preconception care: caffeine, smoking, alcohol, drugs and other environmental chemical/radiation exposure. Reprod Health 2014; 11: S6.
13. Conde-Agudelo A, Rosas-Bermúdez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA 2006; 295: 1809-1823.
14. Hanley GE, Hutcheon JA, Kinniburgh BA, Lee L. Interpregnancy interval and adverse pregnancy outcomes: an analysis of successive pregnancies. Obstet Gynecol 2017; 129: 408-415.
15. Guerin A, Nisenbaum R, Ray JG. Use of maternal GHb concentration to estimate the risk of congenital anomalies in the offspring of women with prepregnancy diabetes. Diabetes Care 2007; 30: 1920-1925.
16. Lassi ZS, Imam AM, Dean SV, Bhutta ZA. Preconception care: screening and management of chronic disease and promoting psychological health. Reprod Health 2014; 11: S5.
17. Australian Government Department of Health. Immunisation for pregnancy. https://beta.health.gov.au/health-topics/immunisation/immunisation-throughout-life/immunisation-for-pregnancy (viewed Sept 2018).
18. Zaballa K, Liu A, Peek MJ, et al. Association between World Health Organization categories of body mass index and relative risks for weight-related pregnancy outcomes: a retrospective cohort study. Obstet Med 2012; 5: 112-118.
19. Oteng-Ntim E, Mononen S, Sawicki O, et al. Interpregnancy weight change and adverse pregnancy outcomes: a systematic review and meta-analysis. BMJ Open 2018; 8: e018778.

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Perspectives

Endemic unprofessional behaviour in health care: the mandate for a change in approach

Johanna Westbrook, Neroli Sunderland, Victoria Atkinson, Catherine Jones and Jeffrey Braithwaite

Med J Aust 2018; 209 (9): . || doi: 10.5694/mja17.01261
Published online: 5 November 2018

Topics

Health services administration

Medical education

Ethics and law

Pervasive bullying, discrimination and sexual harassment are increasingly hard to ignore, yet evidence of effective interventions is lacking

Unprofessional behaviour is sufficiently widespread in the Australian health care system that it could be considered endemic. The 2016 survey of the Victorian Public Sector Commission found that 25% of staff in health agencies experienced bullying,1 and in a 2014 survey of the Australian Nursing and Midwifery Federation, 40% of nurses reported bullying or harassment in the previous 12 months.2 In 2015, the Royal Australasian College of Surgeons surveyed 3516 surgical Fellows, trainees and international medical graduates and found that 49% had been subjected to discrimination, bullying, harassment or sexual harassment.3 The Australasian College for Emergency Medicine released in 2017 its survey results: 34% of respondents had experienced bullying, 21.7% discrimination, 16.1% harassment and 6.2% sexual harassment.4 Thus, unsurprisingly, the 2016 Senate inquiry into the medical complaints process concluded that bullying, discrimination and harassment levels remain disconcertingly high despite the apparent “zero tolerance” approach reported by medical administrators and colleges.5

1 Australian Institute of Health Innovation, Macquarie University, Sydney, NSW
2 St Vincent's Health Australia, Melbourne, VIC

Correspondence: johanna.westbrook@mq.edu.au

Acknowledgements:

The authors are recipients of a National Health and Medical Research Council Partnership Project Grant (1134459) for this work.

Competing interests:

Victoria Atkinson and Catherine Jones are employees of St Vincent’s Health Australia.

1. Victorian Auditor-General. Bullying and harassment in the health sector: Victorian Auditor-General’s report. Melbourne: Victorian Auditor General’s Office; 2016. https://www.audit.vic.gov.au/sites/default/files/20160323-Bullying.pdf (viewed Nov 2017).
2. De Cieri H, Shea T, Sheehan C, et al. Leading indicators of OHS performance in the health services: a report on a survey of Australian Nursing and Midwifery Federation (Victorian Branch) members. Melbourne: Monash University; 2015.
3. Royal Australasian College of Surgeons. Expert Advisory Group advising the Royal Australasian College of Surgeons: discrimination, bullying and sexual harassment prevalence survey. Melbourne: RACS, 2015. https://surgeons.org/media/22045682/PrevalenceSurvey_Summary-of-Facts_FINAL.pdf (viewed Nov 2017).
4. Australasian College for Emergency Medicine. ACEM to tackle bullying and harassment. Melbourne: ACEM; 2017. https://acem.org.au/News/Aug-2017/ACEM-to-tackle-bullying-and-harassment (viewed Nov 2017).
5. Senate Standing Committee on Community Affairs. Medical complaints process in Australia. Canberra: Parliament of Australia; 2016. http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Medical_Complaints (viewed Nov 2017).
6. Hickson BG, Pichert WJ, Webb EL, Gabbe SG. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Acad Med 2007; 82: 1040-1048.
7. Loerbroks A, Weigl M, Li J, et al. Workplace bullying and depressive symptoms: a prospective study among junior physicians in Germany. J Psychosom Res 2015; 78: 168-172.
8. Reknes I, Pallesen S, Magerøy N, et al. Exposure to bullying behaviors as a predictor of mental health problems among Norwegian nurses: results from the prospective SUSSH-survey. Int J Nurs Stud 2014; 51: 479-487.
9. Rosenstein A, O’Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf 2008; 34: 464-471.
10. Rosenstein AH. Nurse–physician relationships: impact on nurse satisfaction and retention. Am J Nurs 2002; 102: 26-34.
11. Ortega A, Christensen KB, Hogh A, et al. One-year prospective study on the effect of workplace bullying on long-term sickness absence. J Nurs Manag 2011; 19: 752-759.
12. Nielsen MB, Indregard AM, Øverland S. Workplace bullying and sickness absence: a systematic review and meta-analysis of the research literature. Scand J Work Environ Health 2016; 42: 359-370.
13. Hickson GB, Federspiel CF, Pichert JW, et al. Patient complaints and malpractice risk. JAMA 2002; 287: 2951-2957.
14. Hickson GB, Federspiel CF, Blackford J, et al. Patient complaints and malpractice risk in a regional healthcare center. South Med J 2007; 100: 791-796.
15. Rawson JV, Thompson N, Sostre G, et al. The cost of disruptive and unprofessional behaviors in health care. Acad Radiol 2013; 20: 1074-1076.
16. Riskin A, Erez A, Foulk TA, et al. The impact of rudeness on medical team performance: a randomized trial. Pediatrics 2015; 136: 487-495.
17. Cooper WO, Guillamondegui O, Hines OJ, et al. Use of unsolicited patient observations to identify surgeons with increased risk for postoperative complications. JAMA Surg 2017; 152: 522-529.
18. Cruess RL, Cruess SR, Steinert Y. Amending Miller’s pyramid to include professional identity formation. Acad Med 2016; 91: 180-185.
19. Rees CE, Monrouxe LV. Who are you and who do you want to be? Key considerations in developing professional identities in medicine. Med J Aust 2018; 209: 202-203. <MJA full text>
20. Foster K, Roberts C. The heroic and the villainous: a qualitative study characterising the role models that shaped senior doctors’ professional identity. BMC Med Educ 2016; 16: 206.
21. Scott KM, Caldwell PH, Barnes EH, Barrett J. “Teaching by humiliation” and mistreatment of medical students in clinical rotations: a pilot study. Med J Aust 2015; 203: 185. <MJA full text>
22. Gillen PA, Sinclair M, Kernohan WG, et al. Interventions for prevention of bullying in the workplace. Cochrane Database Syst Rev 2017; 1: CD009778.
23. Leiter MP, Laschinger HKS, Day A, Oore DG. The impact of civility interventions on employee social behavior, distress, and attitudes. J Appl Psychol 2011; 96: 1258-1274.
24. Osatuke K, Leiter M, Belton L, et al. Civility, Respect and Engagement at the Workplace (CREW): a national organization development program at the Department of Veterans Affairs. Journal of Management Policies and Practices 2013; 1: 25-34.
25. Webb LE, Dmochowski RR, Moore IN, et al. Using coworker observations to promote accountability for disrespectful and unsafe behaviors by physicians and advanced practice professionals. Jt Comm J Qual Patient Saf 2016; 42: 149-164.
26. Medew J. Royal Melbourne Hospital targets bullying with new Cognitive Institute program. The Age (Melbourne) 2016; 28 May. https://www.theage.com.au/national/victoria/royal-melbourne-hospital-targets-bullying-with-new-cognitive-institute-program-20160527-gp5377.html (viewed Apr 2018).
27. Atkinson V, Jones, C. The St Vincent’s Ethos Program is “redefining normal” with a pragmatic approach to addressing unprofessional behaviour [unpublished presentation]. 34th International Society for Quality in Healthcare Conference. London (United Kingdom), 1-4 Oct 2017. https://www.isqua.org/research/resources.html?page=1&search=&types%5B3%5D=3&date_range_start=&date_range_end=&events%5B1%5D=1 (viewed Apr 2018).
28. Montgomery A, Panagopoulou E, Kehoe I, Valkanos E. Connecting organisational culture and quality of care in the hospital: is job burnout the missing link? J Health Organ Manag 2011; 25: 108-123.

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Methods of melanoma detection and of skin monitoring for individuals at high risk of melanoma: new Australian clinical practice guidelines

Topics

Abstract

Forty years of “Waltzing Matilda”: the history of the multichannel cochlear implant

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The MJA–Lancet Countdown on health and climate change: Australian policy inaction threatens lives

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Summary

Reducing cardiovascular risk in people with diabetes and kidney disease

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Deprescribing proton pump inhibitors: why, when and how

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Gluten in “gluten-free” manufactured foods in Australia: a cross-sectional study

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Preventing ovarian failure associated with chemotherapy

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Summary

Updated clinical practice guidelines on pregnancy care

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Abstract

Pre-conception care: an important yet underutilised preventive care strategy

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Endemic unprofessional behaviour in health care: the mandate for a change in approach

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Pagination