MJA
MJA

    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

    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.

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      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

      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.
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      • 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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        A perfect storm: towards reducing the risk of suicide in the medical profession

        Ann I McCormack
        Med J Aust 2018; 209 (9): . || doi: 10.5694/mja18.00221
        Published online: 5 November 2018

        Helping doctors build resilience may be protective against burnout and suicide in times of personal hardship

        Having successive generations of doctors in one family — a “medical pedigree” — was once a source of great pride. As the daughter of a doctor and now a mother, I am surprised to find myself hoping my own children do not follow in my footsteps. This is not because of my own career dissatisfaction. In fact, my work is immensely rewarding, but recently, I have been reflecting on the hardships a medical career entails: the gruelling training pathway, the complex medical culture and the constant battle to achieve a work–life balance. I have now witnessed the devastating personal consequences when the rocky road seems impossible to navigate. Over a matter of months, two female junior doctors committed suicide, and more recently, suicide entered my inner circle with the death of one my close male colleagues. Such stories are not unusual in our profession. I do not claim any expertise in this field, but what seems clear to me is that inherent traits in the individuals who choose a career in medicine, and often create excellent doctors, also set them up for high rates of distress. We have a medical workforce that has gone through rapid evolutionary change, and if we combine these factors with exposure to dysfunctional aspects of our medical culture or personal stressors, we have ingredients for a perfect storm.


        • 1 St Vincent's Hospital, Sydney, NSW
        • 2 Garvan Institute of Medical Research, Sydney, NSW


        Correspondence: a.mccormack@garvan.org.au
        Acknowledgements: 

        I thank Yael Barnett for assistance in setting up Vinnies Women in Medicine and reviewing a draft of this manuscript.

        Competing interests:

        No relevant disclosures.

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        • 2. Collier R. Physician suicide too often “brushed under the rug”. CMAJ 2017; 189: E1240-E1241.
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        • 7. Halliday L, Walker A, Vig S, et al. Grit and burnout in UK doctors: a cross-sectional study across specialties and stages of training. Postgrad Med J 2017; 93: 389-394.
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        • 10. Guille C, Frank E, Zhao Z, et al. Work–family conflict and the sex difference in depression among training physicians. JAMA Intern Med 2017; 177: 1766-1772.
        • 11. Australian Medical Association. National Code of Practice — hours of work, shiftwork and rostering for hospital doctors. Kingston, ACT: AMA; 2016. https://ama.com.au/article/national-code-practice-hours-work-shiftwork-and-rostering-hospital-doctors (viewed Sept 2018).
        • 12. Parr JM, Pinto N, Hanson M, et al. Medical graduates, tertiary hospitals, and burnout: a longitudinal cohort study. Ochsner J 2016; 16: 22-26.
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        • 14. Chand SP, Chibnall JT, Slavin SJ. Cognitive behavioral therapy for maladaptive perfectionism in medical students: a preliminary investigation. Acad Psychiatry 2018; 42: 58-61.
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        • 16. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc 2017; 92: 129-146.
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          The first published randomised controlled trial of laser treatment for vaginal atrophy raises serious questions

          Melissa J Buttini and Christopher Maher
          Med J Aust 2018; 209 (9): . || doi: 10.5694/mja18.00187
          Published online: 5 November 2018

          We still await well conducted RCTs of CO2 laser therapy for vaginal atrophy; in the meantime, topical oestrogen therapy remains the gold standard

          Vaginal laser therapy has entered the global marketplace promising women relief from symptoms of genitourinary syndrome of menopause (GSM), formerly known as vulvovaginal atrophy.


          • 1 The Wesley Hospital, Brisbane, QLD
          • 2 University of Queensland, Brisbane, QLD


          Correspondence: melissa.buttini0@gmail.com
          Competing interests:

          No relevant disclosures.

          • 1. American College of Obstetricians and Gynecologists: Fractional laser treatment of vulvovaginal atrophy and US Food and Drug Administration clearance: position statement. Washington, DC: ACOG, approved May 2016, reaffirmed July 2018. https://www.acog.org/Clinical-Guidance-and-Publications/Position-Statements/Fractional-Laser-Treatment-of-Vulvovaginal-Atrophy-and-US-Food-and-Drug-Administration-Clearance (viewed Sept 2018).
          • 2. Therapeutic Goods Administration. Public summary for ARTG entry: 106780 High Tech Laser Australia P/L. https://www.ebs.tga.gov.au/servlet/xmlmillr6?dbid=ebs/PublicHTML/pdfStore.nsf&docid=B5C3E89B35339C9ECA2577DD0001F0EB&agid=(PrintDetailsPublic)&actionid=1 (viewed Feb 2018).
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          • 4. Chollet JA. Efficacy and safety of ultra-low-dose Vagifem (10 mcg). Patient Prefer Adherence 2011; 5: 571-574.
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          • 6. Salvatore S, Nappi RE, Zerbinati N, et al. A 12-week treatment with fractional CO2 laser for vulvovaginal atrophy: a pilot study. Climacteric 2014; 17: 363-369.
          • 7. Salvatore S, Nappi RE, Parma M, et al. Sexual function after fractional microablative CO2 laser in women with vulvovaginal atrophy. Climacteric 2015; 18: 219-225.
          • 8. Salvatore S, Leone Roberti Maggiore U, Athanasiou S, et al. Histological study on the effects of microablative fractional CO2 laser on atrophic vaginal tissue: an ex vivo study. Menopause 2015; 22: 845-849.
          • 9. Athanasiou S, Pitsouni E, Antonopoulou S, et al. The effect of microablative fractional CO2 laser on vaginal flora of postmenopausal women. Climacteric 2016; 19: 512-518.
          • 10. Pitsouni E, Grigoriadis T, Tsiveleka A, et al. Microablative fractional CO2 laser therapy and the genitourinary syndrome of menopause: an observational study. Maturitas 2016; 94: 131-136.
          • 11. Salvatore S, Pitsouni E, Del Deo F, et al. Sexual function in women suffering from genitourinary syndrome of menopause treated with fractionated CO2 laser. Sex Med Rev 2017; 5: 486-494.
          • 12. Athanasiou S, Pitsouni E, Falagas ME, et al. CO2 laser for the genitourinary syndrome of menopause. How many laser sessions? Maturitas 2017; 104: 24-28.
          • 13. Cruz VL, Steiner ML, Pompei LM, et al. Randomized, double-blind, placebo-controlled clinical trial for evaluating the efficacy of fractional CO2 laser compared with topical estriol in the treatment of vaginal atrophy in postmenopausal women. Menopause 2018; 25: 21-28.
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            Revised Australian national guidelines for colorectal cancer screening: family history

            Mark A Jenkins, Driss Ait Ouakrim, Alex Boussioutas, John L Hopper, Hooi C Ee, Jon D Emery, Finlay A Macrae, Albert Chetcuti, Laura Wuellner and D James B St John
            Med J Aust 2018; 209 (10): . || doi: 10.5694/mja18.00142
            Published online: 29 October 2018

            Abstract

            Introduction: Screening is an effective means for colorectal cancer prevention and early detection. Family history is strongly associated with colorectal cancer risk. We describe the rationale, evidence and recommendations for colorectal cancer screening by family history for people without a genetic syndrome, as reported in the 2017 revised Australian guidelines.

            Main recommendations: Based on 10-year risks of colorectal cancer, people at near average risk due to no or weak family history (category 1) are recommended screening by immunochemical faecal occult blood test (iFOBT) every 2 years from age 50 to 74 years. Individuals with moderate risk due to their family history (category 2) are recommended biennial iFOBT from age 40 to 49 years, then colonoscopy every 5 years from age 50 to 74 years. People with a high risk due to their family history (category 3) are recommended biennial iFOBT from age 35 to 44 years, then colonoscopy every 5 years from age 45 to 74 years.

            Changes in management as a result of the guidelines: By 2019, the National Bowel Cancer Screening Program will offer all Australians free biennial iFOBT screening from age 50 to 74 years, consistent with the recommendations in these guidelines for category 1. Compared with the 2005 guidelines, there are some minor changes in the family history inclusion criteria for categories 1 and 2; the genetic syndromes have been removed from category 3 and, as a consequence, colonoscopy screening is now every 5 years; and for categories 2 and 3, screening begins with iFOBT for people aged 40 and 35 years, respectively, before transitioning to colonoscopy after 10 years.


            • 1 University of Melbourne, Melbourne, VIC
            • 2 Royal Melbourne Hospital, Melbourne, VIC
            • 3 Sir Charles Gardiner Hospital, Perth, WA
            • 4 Cancer Council Australia, Sydney, NSW
            • 5 Agency for Clinical Innovation, Sydney, NSW
            • 6 Cancer Council Victoria, Melbourne, VIC


            Correspondence: m.jenkins@unimelb.edu.au
            Acknowledgements: 

            Mark Jenkins has a Research Fellowship from the NHMRC.

            Competing interests:

            Albert Chetcuti and Laura Wuellner are employed by Cancer Council Australia to assist in the preparation of these guidelines — Cancer Council Australia received financial support from both Cancer Council Australia and the Australian Government Department of Health. Mark Jenkins, Jon Emery, Finlay Macrae and James St. John received travel support from Cancer Council Australia to attend meetings for development of the guidelines. Mark Jenkins, Jon Emery, Finlay Macrae and James St. John are members of the Clinical Advisory Group of the National Bowel Cancer Screening Program and received travel support and sitting fees.

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            • 48. Chen CH, Tsai MK, Wen CP. Extending colorectal cancer screening to persons aged 40 to 49 years with immunochemical fecal occult blood test: a prospective cohort study of 513,283 individuals. J Clin Gastroenterol 2016; 50: 761-768.
            • 49. Chen YY, Chen TH, Su MY, et al. Accuracy of immunochemical fecal occult blood test for detecting colorectal neoplasms in individuals undergoing health check-ups. Adv Dig Med 2014; 1: 74-79.
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              Redefining the physician’s role in the era of online health information

              Susan Ieraci
              Med J Aust 2018; 209 (8): . || doi: 10.5694/mja18.00652
              Published online: 15 October 2018

              Clinicians are no longer gatekeepers to privileged information, but rather interpreters, problem solvers, and advisers

              Many readers will be accessing the MJA via the internet: on computers, laptops, phones, or tablets. It is therefore essential that we discuss and understand how the internet and social media are used by patients to find health information, as well as the influence that the medical profession might have on such online information.


              • Emergency medicine consultant, Sydney


              Correspondence: sieraci@ozemail.com.au
              Competing interests:

              I am an executive member of Friends of Science in Medicine.

              • 1. Cocco AM, Zordan R, Taylor DM, et al. Dr Google in the ED: searching for online health information by adult emergency department patients. Med J Aust 2018; 209: 342-347.
              • 2. Thompson A. Hippocrates and the smart phone: the evolving parent and doctor relationship. J Paediatr Child Health 2016; 52: 366-369.
              • 3. Hartzband P, Groopman J. Untangling the web — patients, doctors, and the Internet. N Engl J Med 2010; 362: 1063-1066.
              Online responses are no longer available. Please refer to our instructions for authors page for more information.

                Subclavian vein thrombosis with internal jugular vein extension in an Australian rules football player

                John WP Wong, Fiona WY Lai and Ian Wilson
                Med J Aust 2018; 209 (8): . || doi: 10.5694/mja18.00335
                Published online: 15 October 2018

                Clinical record


                • 1 Royal Melbourne Hospital, Melbourne, VIC
                • 2 Northeast Health Wangaratta, Wangaratta, VIC
                • 3 Rural Health, University of Melbourne, Shepparton, VIC


                Correspondence: johnwpwong@gmail.com
                Competing interests:

                No relevant disclosures.

                • 1. Esmon CT. Basic mechanisms and pathogenesis of venous thrombosis. Blood Rev 2009; 23: 225-229.
                • 2. Bernardi E, Pesavento R, Prandoni P. Upper extremity deep venous thrombosis. Semin Thromb Hemost 2006; 32: 729-736.
                • 3. Lindblad B, Tengborn L, Bergqvist D. Deep vein thrombosis of the axillary-subclavian veins: epidemiologic data, effects of different types of treatment and late sequelae. Eur J Vasc Surg 1998; 2: 161-165.
                • 4. Alla VM, Natarajan N, Kaushik M, et al. Paget–Schroetter syndrome: review of pathogenesis and treatment of effort thrombosis. West J Emerg Med 2010; 11: 358-362.
                • 5. Héron E, Lozinguez O, Alhenc-Gelas M, et al. Hypercoaguable states in primary upper-extremity deep vein thrombosis. Arch Intern Med 2000; 160: 382-386.
                • 6. Elman EE, Kahn SR. The post-thrombotic syndrome after upper extremity deep venous thrombosis in adults: a systematic review. Thromb Res 2006; 117: 609-614.
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                  Australia is responding to the complex challenge of overdiagnosis

                  Ray Moynihan, Alexandra L Barratt, Rachelle Buchbinder, Stacy M Carter, Thomas Dakin, Jan Donovan, Adam G Elshaug, Paul P Glasziou, Christopher G Maher, Kirsten J McCaffery and Ian A Scott
                  Med J Aust 2018; 209 (8): . || doi: 10.5694/mja17.01138
                  Published online: 15 October 2018

                  An Australian alliance of clinical, consumer, research and public organisations is emerging to tackle overdiagnosis

                  Overdiagnosis is now a health challenge recognised across many nations.1 Debates about its definition continue, but in short, overdiagnosis happens when health systems routinely diagnose people in ways that do not benefit them or that even do more harm than good.2 Overdiagnosis is unwarranted diagnosis, leading to harms from unnecessary labels and treatments and to the waste of health care resources that could be better spent dealing with genuine needs. To manage overdiagnosis and the sustainability of the health system more broadly, reversing the harm of too much medicine is becoming a health care priority, demanding effective responses in policy and practice. In Australia, a new alliance is developing a national plan to deal with this problem.


                  • 1 Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD
                  • 2 University of Sydney, Sydney, NSW
                  • 3 Cabrini Institute, Melbourne, VIC
                  • 4 Monash University, Melbourne, VIC
                  • 5 University of Wollongong, Wollongong, NSW
                  • 6 Consumers Health Forum of Australia, Canberra, ACT
                  • 7 Menzies Centre for Health Policy, University of Sydney, Sydney, NSW
                  • 8 George Institute for Global Health, University of Sydney, Sydney, NSW
                  • 9 Princess Alexandra Hospital, Brisbane, QLD
                  • 10 University of Queensland, Brisbane, QLD


                  Correspondence: RayMoynihan@bond.edu.au
                  Competing interests:

                  All authors were involved in planning the 2017 National Summit on Overdiagnosis.

                  • 1. Welch G, Schwartz L, Woloshin S. Overdiagnosed: making people sick in the pursuit of health. Boston: Beacon; 2012.
                  • 2. Carter SM, Degeling C, Doust J, Barratt A. A definition and ethical evaluation of overdiagnosis. J Med Ethics 2016; 42: 705-714
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                  • 4. Hoffman JR, Cooper RJ. Overdiagnosis of disease: a modern epidemic. Arch Intern Med 2012; 172: 1123-1124.
                  • 5. Vaccarella S, Franceschi S, Bray F, et al. Worldwide thyroid-cancer epidemic? The increasing impact of overdiagnosis. N Engl J Med 2016; 375: 614-617.
                  • 6. Glasziou P, Moynihan R, Richards T, Godlee F. Too much medicine; too little care. BMJ 2013; 346: f4247.
                  • 7. Elshaug AG, Watt AM, Mundy L, Willis CD. Over 150 potentially low-value health care practices: an Australian study. Med J Aust 2012; 197: 556-560. <MJA full text>
                  • 8. Maxwell S, O’Leary P, Slevin T, Moorin R. The increase in cancer prevalence and hospital burden in Western Australia 1992–2011. Popul Health Metr 2014; 12: 33.
                  • 9. Treadwell J, McCartney M. Overdiagnosis and overtreatment. Br J Gen Pract 2016; 66: 116-117.
                  • 10. Québec Medical Association. Overdiagnosis: findings and action plan. Québec Medical Association; 2014. www.amq.ca/images/stories/documents/m%C3%A9moires/surdiagnostic-plan-action-en.pdf (viewed Jan 2018).
                  • 11. Saini V, Garcia-Armesto S, Klemperer D, et al. Drivers of poor medical care. Lancet 2017; 358: 178-190.
                  • 12. Pathirana T, Clark J, Moynihan R. Mapping the drivers of overdiagnosis to potential solutions. BMJ 2017; 358: j3879.
                  • 13. Scott IA, Soon J, Elshaug A, Lindner R. Countering cognitive biases in minimising low value care. Med J Aust 2017; 206: 407-411. <MJA full text>
                  • 14. MacMahon H, Naidich DP, Goo JM, et al. Guidelines for management of incidental pulmonary nodules detected on CT images: from the Fleischner Society 2017. Radiology 2017; 284: 228-243.
                  • 15. Soon J, Buchbinder R, Close J, et al. Identifying low-value care: the Royal Australasian College of Physicians’ EVOLVE initiative. Med J Aust 2016; 204: 180-181. <MJA full text>
                  Online responses are no longer available. Please refer to our instructions for authors page for more information.

                    Trials and tribulations: improving outcomes for adolescents and young adults with rare and low survival cancers

                    Adam Walczak, Pandora Patterson and David Thomas
                    Med J Aust 2018; 209 (8): . || doi: 10.5694/mja17.00976
                    Published online: 15 October 2018

                    Coordinated national action is needed to develop an evidence base and standards of care for young Australians with rare and low survival cancers

                    In November 2016, the Australian Senate established a select committee to explore the impact of funding models on rare and low survival cancer research. CanTeen Australia presented a submission to this inquiry which highlighted the impact of these cancers on adolescents and young adults (AYAs) and the systemic barriers to improving outcomes for patients with rare and low survival cancers. Drawing from that submission, we present the argument for a strategic national approach, including a national trial network, to facilitate cross-sectoral coordination and investment to improve outcomes for AYA patients with cancer and the broader Australian population affected by rare and low survival cancers.


                    • 1 CanTeen Australia, Sydney, NSW
                    • 2 Cancer Nursing Research Unit, University of Sydney, Sydney, NSW
                    • 3 Kinghorn Cancer Centre, Garvan Institute of Medical Research, Sydney, NSW
                    • 4 University of New South Wales, Sydney, NSW


                    Correspondence: adam.walczak@canteen.org.au
                    Acknowledgements: 

                    We thank Peter Orchard and Kimberley Allison for their contributions to the development of this manuscript.

                    Competing interests:

                    CanTeen Australia received Commonwealth Government funding to support the Australian Young Cancer Patient Clinical Trials Initiative.

                    • 1. Australian Institute of Health and Welfare. Cancer in adolescents and young adults in Australia (AIHW Cat. No. CAN 59; Cancer Series No. 62). Canberra: AIHW; 2011. https://www.aihw.gov.au/reports/cancer/cancer-in-adolescents-and-young-adults-in-australi/contents/table-of-contents (viewed Sept 2017).
                    • 2. Bleyer A, Budd T, Montello M. Adolescents and young adults with cancer: the scope of the problem and criticality of clinical trials. Cancer 2006; 107: 1645-1655.
                    • 3. Thomas DM, Seymour JF, O’Brien T, et al. Adolescent and young adult cancer: a revolution in evolution? Intern Med J 2006; 36: 302-307.
                    • 4. Rare Cancers Australia. Just a little more time: rare cancers update report. Bowral, Australia: Rare Cancers Australia; 2016. https://www.rarecancers.org.au/page/1081/reports-submissions (viewed Oct 2017).
                    • 5. Bleyer A. Adolescent and young adult (AYA) cancers: distinct biology, different therapy? Cancer Forum 2009; 33: 4-10.
                    • 6. Tricoli JV, Blair DG, Anders CK, et al. Biologic and clinical characteristics of adolescent and young adult cancers: Acute lymphoblastic leukemia, colorectal cancer, breast cancer, melanom, and sarcoma. Cancer 2016; 122: 1017-1028.
                    • 7. Bond MC, Pritchard S. Understanding clinical trials in childhood cancer. Paediatr Child Health 2006; 11: 148-150.
                    • 8. Mitchell AE, Scarcella DL, Rigutto GL, et al. Cancer in adolescents and young adults: treatment and outcome in Victoria. Med J Aust 2004; 180: 59-62. <MJA full text>
                    • 9. Teenage Cancer Trust. Giving more young people with cancer the opportunity to take part in clinical trials. London: Teenage Cancer Trust; 2014. https://teenagecancertrust.org/sites/default/files/Clinical%20Trials%20Paper_JR_FINAL_April15.pdf (viewed Oct 2017).
                    • 10. Abrahamyan L, Feldman BM, Tomlinson G, et al. Alternative designs for clinical trials in rare diseases. Am J Med Genet C Semin Med Genet 2016; 172: 313-331.
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                    • 12. Casali PG, Bruzzi P, Bogaerts J, Blay JY. Rare Cancers Europe (RCE) methodological recommendations for clinical studies in rare cancers: a European consensus position paper. Ann Oncol 2015; 26: 300-306.
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                    Online responses are no longer available. Please refer to our instructions for authors page for more information.

                      Translation and implementation of the Australian-led PCOS guideline: clinical summary and translation resources from the International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome

                      Helena J Teede, Marie L Misso, Jacqueline A Boyle, Rhonda M Garad, Veryan McAllister, Linda Downes, Melanie Gibson-Helm, Roger J Hart, Luk Rombauts, Lisa Moran, Anuja Dokras, Joop Laven, Terhi Piltonen, Raymond J Rodgers, Mala Thondan, Michael F Costello and Robert J Norman, on behalf of the International PCOS Network
                      Med J Aust 2018; 209 (7): . || doi: 10.5694/mja18.00656
                      Published online: 1 October 2018

                      Abstract

                      Introduction: We have developed the first international evidence-based guideline for the diagnosis and management of polycystic ovary syndrome (PCOS), with an integrated translation program incorporating resources for health professionals and consumers. The development process involved an extensive Australian-led international and multidisciplinary collaboration of health professionals and consumers over 2 years. The guideline is approved by the National Health and Medical Research Council and aims to support both health professionals and women with PCOS in improving care, health outcomes and quality of life. A robust evaluation process will enable practice benchmarking and feedback to further inform evidence-based practice. We propose that this methodology could be used in developing and implementing guidelines for other women’s health conditions and beyond.

                      Main recommendations: The recommendations cover the following broad areas: diagnosis, screening and risk assessment depending on life stage; emotional wellbeing; healthy lifestyle; pharmacological treatment for non-fertility indications; and assessment and treatment of infertility.

                      Changes in management as a result of this guideline: •Diagnosis:▪when the combination of hyperandrogenism and ovulatory dysfunction is present, ultrasound examination of the ovaries is not necessary for diagnosis of PCOS in adult women;▪requires the combination of hyperandrogenism and ovulatory dysfunction in young women within 8 years of menarche, with ultrasound examination of the ovaries not recommended, owing to the overlap with normal ovarian physiology; and▪adolescents with some clinical features of PCOS, but without a clear diagnosis, should be regarded as “at risk” and receive follow-up assessment.•Screening for metabolic complications has been refined and incorporates both PCOS status and additional metabolic risk factors.•Treatment of infertility: letrozole is now first line treatment for infertility as it improves live birth rates while reducing multiple pregnancies compared with clomiphene citrate.

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                      • 1 National Health and Medical Research Council Centre for Research Excellence in PCOS, Monash and Adelaide Universities, Melbourne, VIC
                      • 2 Monash Centre for Health Research and Implementation, Monash Public Health and Preventive Medicine, Monash University and Monash Health, Melbourne, VIC
                      • 3 Polycystic Ovary Syndrome Association of Australia, Sydney, NSW
                      • 4 University of Western Australia, Perth, WA
                      • 5 Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC
                      • 6 Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
                      • 7 Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus Medical Centre, Rotterdam, Netherlands
                      • 8 Obstetrics and Gynecology, PEDEGO Research Unit, Medical Research Centre, Oulu University Hospital, Oulu, Finland
                      • 9 Robinson Research Institute, University of Adelaide and Fertility SA, Adelaide, SA
                      • 10 Harp Family Medical Centre, Melbourne, VIC
                      • 11 UNSW Sydney, Sydney, NSW


                      Correspondence: helena.teedee@monash.edu

                      Collaborating authors: Estifanos Baye, Monash Centre for Health Research and Implementation, Melbourne; Leah Brennan, Australian Catholic University, Melbourne; Cheryce Harrison, Monash Centre for Health Research and Implementation, Melbourne; Samantha Hutchison, Monash Health Centre for Research Implementation, Melbourne; Anju Joham, Monash Centre for Health Research and Implementation, Melbourne; Louise Johnson, Victorian Assisted Reproductive Treatment Authority, Melbourne; Cailin Jordan, Genea Hollywood Fertility, Perth; Jayashri Kulkarni, Monash Alfred Psychiatry Research Centre, Melbourne; Darren Mansfield, Monash Health, Melbourne; Kate Marsh, Northside Nutrition and Dietetics, Sydney; Ben W Mol, Monash University, Melbourne; Alexia Peña, Robinson Research Institute, University of Adelaide, Adelaide; Raymond Rodgers, Robinson Research Institute, University of Adelaide, Adelaide; Jane Speight, Deakin University, Geelong; Nigel Stepto, Victoria University, Melbourne; Eliza C Tassone, Monash Centre for Health Research and Implementation, Melbourne; Angela Wan, Monash University, Melbourne; Jane Woolcock, Women’s and Children’s Hospital, Adelaide.

                      Acknowledgements: 

                      We gratefully acknowledge the contribution of the many women with PCOS and health professionals who guided and contributed to this work. We thank our funding, partner, engaged and collaborating organisations for their roles in prioritising topics and identifying gaps, and contributing members for guideline development, providing peer review and assisting with dissemination. We acknowledge those who independently assessed the guideline against AGREEII criteria and completed methodological review, and those within the NHMRC who managed the approval process. This guideline was approved by all members of the guideline development groups and has been approved by the NHMRC.

                      Specifically, our funding, partner, collaborator and engaged organisations include:

                      • The NHMRC through the funded Centre for Research Excellence in Polycystic Ovary Syndrome and the members of this Centre who coordinated this international guideline effort.

                      • Our partner organisations which co-funded the guideline: the American Society for Reproductive Medicine and the European Society of Human Reproduction and Embryology.

                      • Our collaborating and engaged societies and consumer groups: Androgen Excess and Polycystic Ovary Syndrome Society; American Pediatric Endocrine Society; Asia Pacific Paediatric Endocrine Society; Asia Pacific Initiative on Reproduction; Australasian Paediatric Endocrine Group; Australian Diabetes Society; British Fertility Society; Canadian Society of Endocrinology and Metabolism; Dietitians Association Australia; Endocrine Society (US);Endocrine Society Australia; European Society of Endocrinology; European Society for Paediatric Endocrinology; Exercise and Sports Science Australia; Fertility Society Australia; International Society of Endocrinology; International Federation of Fertility Societies; International Federation of Gynaecology and Obstetrics; Italian Society of Gynaecology and Obstetrics; Japanese Society for Paediatric Endocrinology; Latin American Society for Paediatric Endocrinology; Nordic Federation of Societies of Obstetrics and Gynaecology; PCOS Challenge; PCOS Society of India; Paediatric Endocrine Society; Polycystic Ovary Association Australia; Royal Australasian College of Physicians; Royal Australian College of General Practitioners; Royal Australian and New Zealand College of Obstetricians and Gynaecologists; Royal College of Obstetricians and Gynaecologists (UK); South African Society of Gynaecology and Obstetrics; Verity UK; Victorian Assisted Reproductive Technology Association (VARTA).

                      • Our Australian translation partners: Jean Hailes for Women’s Health and VARTA.

                      Funding: The guideline and translation program was primarily funded by the NHMRC Centre for Research Excellence in PCOS grant (APP1078444) and partnership grant (APP1133084). This funding was supported by a partnership with the European Society of Human Reproduction and Embryology and the American Society for Reproductive Medicine. Translation costs were supported by the NHMRC Centre for Research Excellence and partnership grant. Jean Hailes for Women’s Health funded the cost of this MJA supplement.

                      Competing interests:

                      Disclosures of conflicts of interest were declared at the outset and updated throughout the guideline process, aligned with NHMRC guideline processes. Full details of conflicts declared across the guideline development groups are available at guideline in the register of disclosures of interest.

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