Topics

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.

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Supplement

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

Topics

Women's health

Endocrine system diseases

General medicine

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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24. National Institutes of Health. NIH evidence-based methodology workshop on Polycystic Ovary Syndrome: executive summary. 3-5 Dec 2012. https://prevention-archive.od.nih.gov/docs/programs/pcos/FinalReport.pdf (viewed Aug 2018).
25. Davis SR, Knight S, White V, et al. Preliminary indication of a high prevalence of polycystic ovary syndrome in indigenous Australian women. Gynecol Endocrinol 2002; 16: 443-446.
26. Boyle J, Hollands G, Beck S, et al. Process evaluation of a pilot evidence-based Polycystic Ovary Syndrome clinic in the Torres Strait. Aust J Rural Health 2017; 25: 175-181.
27. Australian Bureau of Statistics. 4715.0 National Aboriginal and Torres Strait Islander Health Survey, 2004-05. Canberra: ABS, 2006. http://www.abs.gov.au/ausstats/abs@.nsf/mf/4715.0/ (viewed Jan 2018).
28. Vos T, Barker B, Begg S, et al. Burden of disease and injury in Aboriginal and Torres Strait Islander Peoples: the Indigenous health gap. Int J Epidemiol 2009; 38: 470-477.
29. Hunt J, Marshall AL, Jenkins D. Exploring the meaning of, the barriers to and potential strategies for promoting physical activity among urban Indigenous Australians. Health Promot J Aust 2008; 19: 102-108.
30. Thompson SJ, Gifford SM, Thorpe L. The social and cultural context of risk and prevention: food and physical activity in an urban Aboriginal community. Health Educ Behav 2000; 27: 725-743.
31. Hancock H. Aboriginal women’s perinatal needs, experiences and maternity services: a literature review to enable considerations to be made about quality indicators. Ngaanyatjarra Health Service, Dec 2006. https://www.lowitja.org.au/sites/default/files/docs/Ngaanyatjarra-Health-Service-Lit-Review.pdf (viewed Aug 2018).
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Narrative review

Management of inflammatory bowel disease

Emily K Wright, Nik S Ding and Ola Niewiadomski

Med J Aust 2018; 209 (7): . || doi: 10.5694/mja17.01001
Published online: 1 October 2018

Topics

Digestive system diseases

Immune system diseases

Summary

Australia has one of the highest incidence rates of inflammatory bowel disease (IBD) in the world.
Early diagnosis and treatment for IBD is critical. For Crohn disease, in particular, this may change the natural history of disease and reduce disability.
Faecal calprotectin is a sensitive test that can be used by primary care physicians to assist in determining which patients with gastrointestinal symptoms may have IBD. This allows for prompt identification of patients who may benefit from endoscopy.
Regular re-evaluation of disease status with strategies that can safely, readily and reliably detect the presence of inflammation with faecal biomarkers and imaging is important. To avoid the risks of cumulative radiation exposure, magnetic resonance imaging and/or intestinal ultrasound, rather than computed tomography scanning, should be performed when possible.
Drug treatments for IBD now include five biological drugs listed by the Pharmaceutical Benefits Scheme: adalimumab, infliximab, golimumab, vedolizumab and ustekinumab. Such developments offer the possibility for improved disease control in selected patients.

1 St Vincent's Hospital Melbourne, Melbourne, VIC
2 Box Hill Hospital, Melbourne, VIC

Correspondence: Emily.Wright@svha.org.au

Competing interests:

No relevant disclosures.

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Editorials

A new evidence-based guideline for assessment and management of polycystic ovary syndrome

Robert J Norman and Helena J Teede

Med J Aust 2018; 209 (7): . || doi: 10.5694/mja18.00635
Published online: 1 October 2018

Topics

Women's health

General medicine

Diagnostic techniques and procedures

An Australian-led international and multidisciplinary collaboration has developed new recommendations to improve the care, health outcomes and quality of life of women with PCOS

Polycystic ovary syndrome (PCOS) is one of the most common hormonal conditions in women of reproductive age and often presents in adolescence with further manifestation in later reproductive life.1 Many women are not diagnosed or have long delays before the condition is recognised.2 Key patient needs are not being met well, and knowledge gaps have been shown in both patients and health professionals alike.2,3 This is of particular concern in a condition where the prevalence is generally considered to be between 9% and 18%, depending on the definition and the population studied.4

1 Robinson Research Institute, University of Adelaide, Adelaide, SA
2 Fertility SA, Adelaide, SA
3 Monash Partners Academic Health Sciences Centre, Monash University, Melbourne, VIC

Correspondence: robert.norman@adelaide.edu.au

Acknowledgements:

The Centre of Research Excellence in PCOS is funded by the National Health and Medical Research Council.

Competing interests:

We are co-authors of the International evidence-based guideline for the assessment and management of polycystic ovary syndrome.

1. Norman RJ, Dewailly D, Legro RS, Hickey TE. Polycystic ovary syndrome. Lancet 2007; 370: 685-697.
2. Gibson-Helm M, Teede H, Dunaif A, Dokras A. Delayed diagnosis and a lack of information associated with dissatisfaction in women with polycystic ovary syndrome. J Clin Endocrinol Metab 2017; 102: 604-612.
3. Tata B, Mimouni NEH, Barbotin AL, et al. Elevated prenatal anti-Mullerian hormone reprograms the fetus and induces polycystic ovary syndrome in adulthood. Nat Med 2018; 24: 834-846.
4. Balen AH, Morley LC, Misso M, et al. The management of anovulatory infertility in women with polycystic ovary syndrome: an analysis of the evidence to support the development of global WHO guidance. Hum Reprod Update 2016; 22: 687-708.
5. Teede HJ, Misso ML, Deeks AA, et al. Assessment and management of polycystic ovary syndrome: summary of an evidence-based guideline. Med J Aust 2011; 195 (6 Suppl): S65-S110. <MJA full text>
6. Teede HJ, Misso ML, Costello MF, et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Fertil Steril 2018; 110: 364-379.
7. Teede HJ, Misso ML, Costello MF, et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Hum Reprod 2018; doi: 10.1093/humrep/dey256 [Epub ahead of print].
8. Teede HJ, Misso ML, Costello MF, et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Clin Endocrinol (Oxf) 2018; doi: 10.1111/cen.13795 [Epub ahead of print].
9. Teede HJ, Misso ML, Boyle JA, et al. 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. Med J Aust 2018; 209 (7 Suppl): S1-S23.
10. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 2004; 81: 19-25.
11. Moran LJ, Misso ML, Wild RA, Norman RJ. Impaired glucose tolerance, type 2 diabetes and metabolic syndrome in polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod Update 2010; 16: 347-363.
12. Dokras A, Stener-Victorin E, Yildiz BO, et al. Androgen Excess- Polycystic Ovary Syndrome Society: position statement on depression, anxiety, quality of life, and eating disorders in polycystic ovary syndrome. Fertil Steril 2018; 109: 888-899.

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Perspectives

Pathway to ending avoidable diabetes-related amputations in Australia

Peter A Lazzarini, Jaap J van Netten, Robert A Fitridge, Ian Griffiths, Ewan M Kinnear, Matthew Malone, Byron M Perrin, Jenny Prentice and Paul R Wraight

Med J Aust 2018; 209 (7): . || doi: 10.5694/mja17.01198
Published online: 1 October 2018

Topics

Endocrine system diseases

Health services administration

Skin and connective tissue diseases

Surgical procedures, operative

Wounds and injuries

A new Australian strategy should finally reduce the significant national burden of diabetes-related foot disease

Diabetes-related foot disease (DFD) is “common, complex, and costly”1 and underappreciated in Australia.2 With DFD not even rating a footnote mention in recent national chronic disease strategies,3 it is arguably Australia’s least known major health problem.2 If Australia is to reduce avoidable amputations, major improvements in the way we approach DFD are urgently needed.2,4

1 Queensland University of Technology, Brisbane, QLD
2 Metro North Hospital and Health Service, Brisbane, QLD
3 Amsterdam Movement Sciences, Academic Medical Center, Amsterdam, Netherlands
4 Royal Adelaide Hospital, Adelaide, SA
5 Wound Management Innovation Cooperative Research Centre, Brisbane, QLD
6 Liverpool Hospital, Sydney, NSW
7 La Trobe Rural Health School, La Trobe University, Bendigo, VIC
8 Royal Melbourne Hospital, Melbourne, VIC

Correspondence: Peter.Lazzarini@health.qld.gov.au

Acknowledgements:

Diabetic Foot Australia is kindly supported by grant funding from the Wound Management Innovation Cooperative Research Centre.

Competing interests:

We are all authors of the Australian Diabetes-related Foot Disease Strategy 2018–2022, and members of the steering committee of the Diabetic Foot Australia Wound Management Innovation Cooperative Research Centre.

1. Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med 2017; 376: 2367-2375.
2. Lazzarini PA, Gurr JM, Rogers JR, et al. Diabetes foot disease: the Cinderella of Australian diabetes management? J Foot Ankle Res 2012; 5: 24.
3. Australian Government Department of Health. Australian National Diabetes Strategy 2016–2020. Canberra: Commonwealth of Australia, 2015. http://www.health.gov.au/internet/main/publishing.nsf/content/nds-2016-2020 (viewed Dec 2017).
4. Van Netten JJ, Lazzarini PA, Fitridge R, et al. Australian diabetes-related foot disease strategy 2018–2022: the first step towards ending avoidable amputations within a generation. Brisbane: Diabetic Foot Australia, 2017. https://www.diabeticfootaustralia.org/for-researchers/australian-diabetes-related-foot-disease-strategy-2018-2022/ (viewed Dec 2017).
5. Australian Commission on Safety and Quality in Health Care. The first Australian atlas of healthcare variation. Sydney: ACSQHC, 2015. https://www.safetyandquality.gov.au/atlas/atlas-2015/ (viewed Aug 2018).
6. Lazzarini PA. The burden of foot disease in inpatient populations [PhD thesis]. Brisbane: Queensland University of Technology, 2016. https://eprints.qut.edu.au/101526/ (viewed Dec 2017).
7. Jupiter DC, Thorud JC, Buckley CJ, Shibuya N. The impact of foot ulceration and amputation on mortality in diabetic patients. I: From ulceration to death, a systematic review. Int Wound J 2016; 13: 892-903.
8. West M, Chuter V, Munteanu S, Hawke F. Defining the gap: a systematic review of the difference in rates of diabetes-related foot complications in Aboriginal and Torres Strait Islander Australians and non-Indigenous Australians. J Foot Ankle Res 2017; 10: 48.
9. Schaper NC, Van Netten JJ, Apelqvist J, et al. Prevention and management of foot problems in diabetes: a Summary Guidance for Daily Practice 2015, based on the IWGDF Guidance Documents. Diabetes Metab Res Rev 2016; 32: 7-15.
10. National evidence-based guideline for the prevention, identification and management of foot complications in diabetes (part of the guidelines on management of type 2 diabetes). Melbourne: Baker IDI Heart and Diabetes Institute, 2011. http://t2dgr.bakeridi.edu.au/ (viewed Dec 2017).
11. Morbach S, Kersken J, Lobmann R, et al. The German and Belgian accreditation models for diabetic foot services. Diabetes Metab Res Rev 2016; 32: 318-325.
12. Bergin SM, Alford JB, Allard BP, et al. A limb lost every 3 hours: can Australia reduce amputations in people with diabetes? Med J Aust 2012; 197: 197-198. <MJA full text>
13. Lazzarini PA, O’Rourke SR, Russell AW, et al. Reduced incidence of foot-related hospitalisation and amputation amongst persons with diabetes in Queensland, Australia. PLoS ONE 2015; 10: e0130609.
14. Cheng Q, Lazzarini PA, Gibb M, et al. A cost-effectiveness analysis of optimal care for diabetic foot ulcers in Australia. Int Wound J 2017; 14: 616-628.
15. van Netten JJ, Baba M, Lazzarini PA. Epidemiology of diabetic foot disease and diabetes-related lower-extremity amputation in Australia: a systematic review protocol. Syst Rev 2017; 6: 101.

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Perspectives

Medical assistance in dying: a disruption of therapeutic relationships

Leeroy William

Med J Aust 2018; 209 (7): . || doi: 10.5694/mja17.01217
Published online: 1 October 2018

Topics

Palliative care

General medicine

Ethics and law

Medical assistance in dying may disrupt therapeutic relationships and will challenge beliefs

Medical assistance in dying, whether voluntary euthanasia or physician-assisted suicide, has been a recurring topic for societal debate. Voluntary euthanasia is the deliberate and intentional act to end a competent person’s life, at their request, to relieve their suffering.1 Physician-assisted suicide relates to the medical provision of the means or knowledge for someone to commit suicide via the self-administration of a prescribed medication.1 Amid growing societal support2 and stability of worldwide medical opinion, there has been a 66% increase in the legalisation of physician-assisted suicide since 2015,3 which indirectly legitimises such practices through the broad influence it has on societal support. Canada and the American states of California and Colorado legalised physician-assisted suicide in 2016.3 In Australia, the Victorian Parliament passed a Bill in 2017 to legalise physician-assisted suicide, while the debate currently continues in other Australian states and New Zealand. By contrast, in May 2018 Guernsey failed to become the first place in Britain to permit physician-assisted suicide.4

1 Eastern Health, Melbourne, VIC
2 Monash University, Melbourne, VIC

Correspondence: leeroy.william@monash.edu

Competing interests:

No relevant disclosures.

1. Queensland University of Technology. End of life law in Australia. Euthanasia and assisted dying. https://end-of-life.qut.edu.au/euthanasia#547411 (accessed Aug 2018).
2. Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA 2016; 316: 79-90.
3. Kennedy Institute of Ethics, Georgetown University. Euthanasia regulations around the world. https://ethicslab.georgetown.edu/euthanasia-map/ (accessed Aug 2018).
4. Sherwood H. Guernsey parliament votes against assisted dying. The Guardian 2018; 18 May. https://www.theguardian.com/society/2018/may/18/guernsey-parliament-votes-against-assisted-dying (accessed Aug 2018).
5. Hendry M, Pasterfield D, Lewis R, et al. Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying. Palliat Med 2012; 27: 13-26.
6. Kelly BJ, Varghese FT, Pelusi D. Countertransference and ethics: a perspective on clinical dilemmas in end-of-life decisions. Palliat Support Care 2003; 1: 367-375.
7. Saini V, Garcia-Armesto S, Klemperer D, et al. Drivers of poor medical care. Lancet 2017; 390: 178-190.
8. Estacio CF, Butow PN, Lovell MR, et al. Exploring symptom meaning: perspectives of palliative care physicians. Support Care Cancer 2018; 26: 2769-2784.
9. Beauchamp TL, Childress JF. Principles of biomedical ethics. 3rd ed. New York, Oxford: Oxford University Press, 1989.
10. Working Party of the Royal College of Physicians. Doctors in society: medical professionalism in a changing world. Clin Med (Lond) 2005; 5 (6 Suppl 1): S5-S40.
11. Bergman YS, Bodner E, Haber Y. The connection between subjective nearness-to-death and depressive symptoms: the mediating role of meaning in life. Psychiatry Res 2018; 261: 269-273.
12. McKenzie EL, Brown PM, Mak AS, Chamberlain P. “Old and ill”: death anxiety and coping strategies influencing health professionals’ well-being and dementia care. Aging Ment Health 2017; 21: 634-641.
13. Belmi P, Pfeffer J. Power and death: mortality salience increases power seeking while feeling powerful reduces death anxiety. J Appl Psychol 2016; 101: 702-720.
14. Virdun C, Luckett T, Lorenz K, et al. Dying in the hospital setting: a meta-synthesis identifying the elements of end-of-life care that patients and their families describe as being important. Palliat Med 2017; 31: 587-601.
15. Smith C, Bosanquet N, Riley J, Koffman J. Loss, transition and trust: perspectives of terminally ill patients and their oncologists when transferring care from the hospital into the community at the end of life. BMJ Support Palliat Care 2016; doi: 10.1136/bmjspcare-2015-001075.
16. Wong PTP, Reker GT, Gesser G. Death attitude profile-revised: a multidimensional measure of attitudes toward death. In: Neimeyer RA. Death anxiety handbook: research, instrumentation, and application. Washington DC: Taylor & Francis, 1994.
17. Thiemann P, Quince T, Benson J, et al. Medical students’ death anxiety: severity and association with psychological health and attitudes toward palliative care. J Pain Symptom Manage 2015; 50: 335-342.

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Research

Surveillance improves survival of patients with hepatocellular carcinoma: a prospective population-based study

Thai P Hong, Paul J Gow, Michael Fink, Anouk Dev, Stuart K Roberts, Amanda Nicoll, John S Lubel, Ian Kronborg, Niranjan Arachchi, Marno Ryan, William W Kemp, Virginia Knight, Vijaya Sundararajan, Paul Desmond, Alexander JV Thompson and Sally J Bell

Med J Aust 2018; 209 (8): . || doi: 10.5694/mja18.00373
Published online: 24 September 2018

Topics

Neoplasms

Digestive system diseases

Environment and public health

Statistics, epidemiology and research design

Abstract

Objectives: To determine the factors associated with survival of patients with hepatocellular carcinoma (HCC) and the effect of HCC surveillance on survival.

Design, setting and participants: Prospective population-based cohort study of patients newly diagnosed with HCC in seven tertiary hospitals in Melbourne, 1 July 2012 – 30 June 2013.

Main outcome measures: Overall survival (maximum follow-up, 24 months); factors associated with HCC surveillance participation and survival.

Results: 272 people were diagnosed with incident HCC during the study period; the most common risk factors were hepatitis C virus infection (41%), alcohol-related liver disease (39%), and hepatitis B virus infection (22%). Only 40% of patients participated in HCC surveillance at the time of diagnosis; participation was significantly higher among patients with smaller median tumour size (participants, 2.8 cm; non-participants, 6.0 cm; P < 0.001) and earlier Barcelona Clinic Liver Cancer (BCLC) stage disease (A/B, 59%; C/D, 25%; P < 0.001). Participation was higher among patients with compensated cirrhosis or hepatitis C infections; it was lower among those with alcohol-related liver disease or decompensated liver disease. Median overall survival time was 20.8 months; mean survival time was 18.1 months (95% CI, 16.6–19.6 months). Participation in HCC surveillance was associated with significantly lower mortality (adjusted hazard ratio [aHR], 0.60; 95% CI, 0.38–0.93; P = 0.021), as were curative therapies (aHR, 0.33; 95% CI, 0.19–0.58). Conversely, higher Child–Pugh class, alpha-fetoprotein levels over 400 kU/L, and later BCLC disease stages were each associated with higher mortality.

Conclusions: Survival for patients with HCC is poor, but may be improved by surveillance, associated with the identification of earlier stage tumours, enabling curative therapies to be initiated.

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1 St Vincent's Hospital Melbourne, Melbourne, VIC
2 Austin Hospital, Melbourne, VIC
3 University of Melbourne, Melbourne, VIC
4 Austin Health, Melbourne, VIC
5 Monash Health, Melbourne, VIC
6 Eastern Health, Melbourne, VIC
7 Western Health, Melbourne, VIC
8 Alfred Hospital, Melbourne, VIC

Correspondence: thai.hong@svha.org.au

Competing interests:

No relevant disclosures.

1. Forman D, Bray F, Brewster DH, et al, editors. Cancer incidence in five continents. Volume X (IARC Scientific Publication No. 164). Lyon: International Agency for Research on Cancer, 2014. http://publications.iarc.fr/Book-And-Report-Series/Iarc-Scientific-Publications/Cancer-Incidence-In-Five-Continents-Volume-X-2014 (viewed Aug 2018).
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10. Heimbach J, Kulik LM, Finn R, et al. AASLD guidelines for the treatment of hepatocellular carcinoma. Hepatology 2018; 67: 358-380.
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12. Davila JA, Henderson L, Kramer JR, et al. Utilization of surveillance for hepatocellular carcinoma among hepatitis C virus-infected veterans in the United States. Ann Intern Med 2011; 154: 85-93.
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14. Hong TP, Gow P, Fink M, et al. Novel population-based study finding higher than reported hepatocellular carcinoma incidence suggests an updated approach is needed. Hepatology 2016; 63: 1205-1212.
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18. Welzel TM, Graubard BI, Quraishi S, et al. Population-attributable fractions of risk factors for hepatocellular carcinoma in the United States. Am J Gastroenterol 2013; 108: 1314-1321.
19. Lin ZH, Xin YN, Dong QJ, et al. Performance of the aspartate aminotransferase-to-platelet ratio index for the staging of hepatitis C-related fibrosis: an updated meta-analysis. Hepatology 2011; 53: 726-736.
20. Bloom S, Kemp W, Nicoll A, et al. Liver stiffness measurement in the primary care setting detects high rates of advanced fibrosis and predicts liver-related events in hepatitis C. J Hepatol 2018; 69: 575-583.
21. Robotin MC, Kansil M, Howard K, et al. Antiviral therapy for hepatitis B-related liver cancer prevention is more cost-effective than cancer screening. J Hepatol 2009; 50: 990-998.
22. Strasser SI. Managing hepatitis B to prevent liver cancer: recent advances. Expert Rev Gastroenterol Hepatol 2014; 8: 409-415.
23. Chen JG, Parkin DM, Chen QG, et al. Screening for liver cancer: results of a randomised controlled trial in Qidong, China. J Med Screen 2003; 10: 204-209.
24. Poustchi H, Farrell GC, Strasser SI, et al. Feasibility of conducting a randomized control trial for liver cancer screening: Is a randomized controlled trial for liver cancer screening feasible or still needed? Hepatology 2011; 54: 1998-2004.
25. Cucchetti A, Trevisani F, Pecorelli A, et al. Estimation of lead-time bias and its impact on the outcome of surveillance for the early diagnosis of hepatocellular carcinoma. J Hepatol 2014; 61: 333-341.

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Meta-analysis

Helicobacter pylori infection and the risk of upper gastrointestinal bleeding in low dose aspirin users: systematic review and meta-analysis

Justin CH Ng and Neville David Yeomans

Med J Aust 2018; 209 (7): . || doi: 10.5694/mja17.01274
Published online: 24 September 2018

Topics

Digestive system diseases

Pharmaceutical preparations

Abstract

Objective: To determine whether the risk of upper gastrointestinal bleeding in patients taking low dose aspirin (≤ 325 mg/day) is increased in people with Helicobacter pylori infections.

Study design: A systematic search for all publications since 1989 (when H. pylori was named) using search term equivalents for “upper gastrointestinal haemorrhage” and “aspirin”. Articles were assessed individually for inclusion of data on H. pylori infection, as not all relevant papers were indexed with this term. Data that could be pooled were then subjected to meta-analysis, using a random effects model.

Data sources: MEDLINE, Embase, Scopus, the Cochrane Library.

Data synthesis: Of 7599 retrieved publications, reports for seven case–control studies contained data suitable for meta-analysis; four were deemed high quality on the Newcastle–Ottawa scale. Upper gastrointestinal haemorrhage was more frequent in aspirin users infected with H. pylori than in those who were not (odds ratio [OR], 2.32; 95% CI, 1.25–4.33; P = 0.008). The heterogeneity of the studies was significant (Q = 19.3, P = 0.004; I² = 68.9%, 95% CI, 31.5–85.9%), but the pooled odds ratio was similar after removing the two studies that contributed most to heterogeneity (OR, 2.34; 95% CI, 1.56–3.53; P < 0.001). The number needed to treat to prevent one bleeding event annually was estimated to be between 100 and more than 1000.

Conclusions: The odds of upper gastrointestinal bleeding in patients taking low dose aspirin is about twice as great in those infected with H. pylori. Testing for and treating the infection should be considered in such patients, especially if their underlying risk of peptic ulcer bleeding is already high.

1 University of Melbourne, Melbourne, VIC
2 Peninsula Health, Melbourne, VIC
3 Austin Health, Melbourne, VIC

Correspondence: JNg@phcn.vic.gov.au

Acknowledgements:

We thank Helen Baxter and Shanti Nadaraja (Austin Health Sciences Library, Austin Health) for expert assistance with the structured literature searches.

Competing interests:

No relevant disclosures.

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Narrative review

When to initiate dialysis for end-stage kidney disease: evidence and challenges

Titi Chen, Vincent WS Lee and David C Harris

Med J Aust 2018; 209 (6): . || doi: 10.5694/mja18.00297
Published online: 17 September 2018

Topics

Urologic diseases

Summary

The decision about when to start dialysis for end-stage kidney disease (ESKD) is complex and is influenced by many factors. ESKD-related symptoms and signs are the most common indications for dialysis initiation. Creatinine-based formulae to estimate glomerular filtration rate (GFR) are inaccurate in patients with ESKD and, thus, the decision to start dialysis should not be based solely on estimated GFR (eGFR).
Early dialysis initiation (ie, at an eGFR > 10 mL/min/1.73 m²) is not associated with a morbidity and mortality benefit, as shown in the Initiating Dialysis Early and Late (IDEAL) study. This observation has been incorporated into the latest guidelines, which place greater emphasis on the assessment of patients’ symptoms and signs rather than eGFR. It is suggested that in asymptomatic patients with stage 5 chronic kidney disease, dialysis may be safely delayed until the eGFR is at least as low as 5–7 mL/min/1.73 m² if there is careful clinical follow-up and adequate patient education.
The decision on when to start dialysis is even more challenging in older patients. Due to their comorbidities and frailty, dialysis initiation may be associated with worse outcomes and quality of life. Therefore, the decision to start dialysis in these patients should be carefully weighed against its risks, and conservative care should be considered in appropriate cases.
To optimise the decision-making process for dialysis initiation, patients need to be referred to a nephrologist in a timely fashion to allow adequate pre-dialysis care and planning. Dialysis initiation and its timing should be a shared decision between physician, patients and family members, and should be tailored to the individual patient’s needs.

University of Sydney, Sydney, NSW

Correspondence: titi.chen@sydney.edu.au

Competing interests:

No relevant disclosures.

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Narrative review

Contemporary approaches to the prevention and management of paediatric obesity: an Australian focus

Seema Mihrshahi, Megan L Gow and Louise A Baur

Med J Aust 2018; 209 (6): . || doi: 10.5694/mja18.00140
Published online: 17 September 2018

Topics

Nutritional and metabolic diseases

Environment and public health

Summary

Of the 34 member countries of the Organisation for Economic Co-operation and Development, obesity prevalence is highest in the United States, with Australia ranking fifth for girls and eighth for boys. Curbing the problem is achievable and can be realised through a combination of smart governance across many sectors, community initiatives, the support of individual efforts, and clinical leadership.
At 5 years of age, one in five Australian children are already affected by overweight or obesity; obesity prevention strategies must therefore start before this age. There is strong evidence that reducing screen time and promoting breastfeeding in 0–2-year-olds are effective interventions in the early years.
The main behavioural risk factors for obesity are overconsumption of energy-dense, nutrient-poor foods and a lack of physical activity. Emerging evidence suggests poor sleep quality and duration and high amounts of sedentary time also play a role.
Systems-based policy actions may change long term obesity prevalence in children by targeting the food environment through nutrition labelling, healthy foods in schools, restricted unhealthy food marketing to children, and fiscal policies to reduce consumption of harmful foods and sugar-sweetened beverages.
Macro-environmental factors influence obesity risk. Public transport policy and the built environment (proximity to parks, bike paths, green space, schools and shops) influence play time spent outdoors, walking and cycling. Greater access to parks and playgrounds and active commuting are associated with lower body mass index.
Australian interventions have largely employed individual level approaches. These are important, but of limited effectiveness unless priority is also given to policies that reduce obesity-conducive environments.
Clinicians can provide anticipatory guidance to support healthy weight and weight-related behaviours, including weight monitoring, early feeding and children’s diets, physical activity opportunities, and limited sedentary and screen time.
Investigations in children with obesity usually include liver function tests and measuring fasting glucose, lipid and possibly insulin levels. As obesity can be associated with micronutrient deficiencies, it may be prudent to check full blood count and iron, vitamin B12 and vitamin D levels. Endocrinological assessment is usually not needed. Second line investigations may include liver ultrasound, oral glucose tolerance testing and sleep study.
Traditional treatment of child and adolescent obesity has focused on family-based, multicomponent (diet, physical activity and behaviour change) interventions, although these lead to small and often short term weight reductions (mean, − 1.45 kg; 95% CI, 1.88 to − 1.02). Nevertheless, these principles remain core interventions in children and adolescents with obesity.
A very low energy diet should be considered in adolescents with severe obesity or obesity-related comorbidities, and for adolescents who have not achieved weight loss following a more conventional dietary approach.
Pharmacotherapy confers only small reductions in weight; for example, effect size for metformin is − 3.90 kg (95% CI, − 5.86 to − 1.94).
Bariatric surgery should be considered in adolescents over 15 years of age with severe obesity (body mass index > 40 kg/m², or > 35 kg/m² in the presence of severe complications).

1 University of Sydney, Sydney, NSW
2 NHMRC Centre of Research Excellence in the Early Prevention of Obesity in Childhood, Sydney, NSW
3 The Children's Hospital at Westmead, Sydney, NSW

Correspondence: Louise.baur@health.nsw.gov.au

Competing interests:

No relevant disclosures.

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