Topics

Respiratory tract diseases

Summary

Lung transplantation in Australia is 32 years old in 2018. From its early infancy in 1986, it continues to evolve and is internationally recognised as demonstrating world’s best practices in organ donation, utilisation and transplantation procedures.
Over the past decade, transplant numbers have increased substantially due to innovations in donor procurement, such as donation after circulatory death, the use of ex vivo lung perfusion, extended criteria and organ utilisation, with more than 200 lung transplants undertaken in Australia annually. Parallel to this, lung transplant outcomes have continued to improve.
While the management of lung transplant recipients is heavily dependent on a tertiary care paradigm, this model is well developed and has been extremely successful, with Australian outcomes exceeding those of the International Society for Heart and Lung Transplantation Registry at all time points.

1 Alfred Hospital, Melbourne, VIC
2 Monash University, Melbourne, VIC

Correspondence: m.paraskeva@alfred.org.au

Competing interests:

No relevant disclosures

1. Hardy JD, Webb WR, Dalton ML Jr, Walker GR Jr. Lung homotransplantation in man. JAMA 1963; 186: 1065-1074.
2. Borel JF, Feurer C, Gubler HU, Stahelin H. Biological effects of cyclosporin A: a new antilymphocytic agent. Agents Actions 1976; 6: 468-475.
3. Reitz BA, Wallwork JL, Hunt SA, et al. Heart-lung transplantation: successful therapy for patients with pulmonary vascular disease. N Engl J Med 1982; 306: 557-564.
4. Toronto Lung Transplant Group. Unilateral lung transplantation for pulmonary fibrosis. N Engl J Med 1986; 314: 1140-1145.
5. Cooper JD, Patterson GA, Grossman R, Maurer J. Double-lung transplant for advanced chronic obstructive lung disease. Am Rev Respir Dis 1989; 139: 303-307.
6. Tait BD. More than a footnote: the story of organ transplantation in Australia and New Zealand. Melbourne: Australian Scholarly, 2012.
7. Chambers DC, Yusen RD, Cherikh WS, et al; The Registry of the International Society for Heart and Lung Transplantation: Thirty-fourth Adult Lung And Heart-Lung Transplantation Report — 2017; Focus Theme: Allograft ischemic time. J Heart Lung Transplant 2017; 36: 1047-1059.
8. Australia and New Zealand Cardiothoracic Organ Transplant Registry. 2016 annual report. ANZCOTR: Sydney. 2016. http://www.anzcotr.org.au/ (viewed Aug 2017).
9. Organ and Tissue Authority. National program. http://www.donatelife.gov.au/about-us/national-reform-programme (viewed Aug 2017).
10. Organ and Tissue Authority. Australian donation and transplantation activity report 2016. Canberra: OTA, 2016. http://www.donatelife.gov.au/sites/default/files/Australian%20Donation%20and%20Transplantation%20Activity%20Report%202016.pdf (viewed Aug 2017).
11. Levin K, Kotecha S, Westall G, Snell G. How can we improve the quality of transplantable lungs? Expert Rev Respir Med 2016: 1-7.
12. Snell GI, Westall GP, Oto T. Donor risk prediction: how ‘extended’ is safe? Curr Opin Organ Transplant 2013; 18: 507-512.
13. Australia and New Zealand Organ Donation Registry. 2016 annual report. Adelaide: ANZOD, 2016. http://www.anzdata.org.au/anzod/v1/reports.html (viewed Aug 2017).
14. Kootstra G, Daemen JH, Oomen AP. Categories of non-heart-beating donors. Transplant Proc 1995; 27: 2893-2894.
15. Cypel M, Levvey B, Van Raemdonck D, et al. International Society for Heart and Lung Transplantation Donation After Circulatory Death Registry report. J Heart Lung Transplant 2015; 34: 1278-1282.
16. Levvey BJ, Harkess M, Hopkins P, et al. Excellent clinical outcomes from a national donation-after-determination-of-cardiac-death lung transplant collaborative. Am J Transplant 2012; 12: 2406-2413.
17. Rakhra SS, Opdam HI, Gladkis L, et al. Untapped potential in Australian hospitals for organ donation after circulatory death. Med J Aust 2017; 207: 294-301. <MJA full text>
18. Transplantation Society of Australia and New Zealand. Organ transplantation from deceased donors: consensus statement on eligibility criteria and allocation protocols. Sydney: TSANZ, 2011. http://www.donatelife.gov.au/sites/default/files/files/TSANZ_Consensus_Statement_V1_1.pdf (viewed Aug 2017).
19. Weill D, Benden C, Corris PA, et al. A consensus document for the selection of lung transplant candidates: 2014 – an update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2015; 34: 1-15.
20. Singer JP, Diamond JM, Gries CJ, et al. Frailty phenotypes, disability, and outcomes in adult candidates for lung transplantation. Am J Respir Crit Care Med 2015; 192: 1325-1334.
21. Wilson ME, Vakil AP, Kandel P, et al. Pretransplant frailty is associated with decreased survival after lung transplantation. J Heart Lung Transplant 2016; 35: 173-178.
22. De Angelis R, Sant M, Coleman MP, et al. Cancer survival in Europe 1999-2007 by country and age: results of EUROCARE–5-a population-based study. Lancet Oncol 2014; 15: 23-34.
23. Vajdic CM, McDonald SP, McCredie MR, et al. Cancer incidence before and after kidney transplantation. JAMA 2006; 296: 2823-2831.
24. Mollberg NM, Farjah F, Howell E, et al. Impact of primary caregivers on long-term outcomes after lung transplantation. J Heart Lung Transplant 2015; 34: 59-64.
25. Castleberry AW, Bishawi M, Worni M, et al. Medication nonadherence after lung transplantation in adult recipients. Ann Thorac Surg 2017; 103: 274-280.
26. Butler JA, Roderick P, Mullee M, et al. Frequency and impact of nonadherence to immunosuppressants after renal transplantation: a systematic review. Transplantation 2004; 77: 769-776.
27. Goldfarb SB, Levvey BJ, Cherikh WS, et al, Registry of the International Society for Heart and Lung Transplantation: Twentieth Pediatric Lung and Heart-Lung Transplantation Report — 2017; Focus Theme: Allograft ischemic time. J Heart Lung Transplant 2017; 36: 1070-1079.
28. Casswell GK, Pilcher DV, Martin RS, et al. Buying time: the use of extracorporeal membrane oxygenation as a bridge to lung transplantation in pediatric patients. Pediatr Transplant 2013; 17: E182-188.
29. Keating DT, Marasco SF, Negri J, et al. Long-term outcomes of cadaveric lobar lung transplantation: helping to maximize resources. J Heart Lung Transplant 2010; 29: 439-444.
30. Paraskeva MA, Edwards LB, Levvey B, et al. Outcomes of adolescent recipients after lung transplantation: an analysis of the International Society for Heart and Lung Transplantation Registry. J Heart Lung Transplant 2018; 37: 323-331.
31. Lowery E, Adams W, Grim S, et al. Increased risk of PTLD in lung transplant recipients with cystic fibrosis. J Cystic Fibrosis 2017; 16: 727-734.
32. Sundaresan S, Trachiotis GD, Aoe M, et al. Donor lung procurement: assessment and operative technique. Ann Thorac Surg 1993; 56: 1409-1413.
33. Orens JB, Boehler A, de Perrot M, et al. A review of lung transplant donor acceptability criteria. J Heart Lung Transplant 2003; 22: 1183-1200.
34. Kotloff RM, Blosser S, Fulda GJ, et al. Management of the potential organ donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations consensus statement. Crit Care Med 2015; 43: 1291-1325.
35. Bansal R, Esan A, Hess D, et al. Mechanical ventilatory support in potential lung donor patients. Chest 2014; 146: 220-227.
36. Angel LF, Levine DJ, Restrepo MI, et al. Impact of a lung transplantation donor-management protocol on lung donation and recipient outcomes. Am J Respir Crit Care Med 2006; 174: 710-716.
37. Pratschke J, Wilhelm MJ, Kusaka M, et al. Brain death and its influence on donor organ quality and outcome after transplantation. Transplantation 1999; 67: 343-348.
38. Mascia L, Pasero D, Slutsky AS, et al. Effect of a lung protective strategy for organ donors on eligibility and availability of lungs for transplantation: a randomized controlled trial. JAMA 2010; 304: 2620-2627.
39. Kirschbaum CE, Hudson S. Increasing organ yield through a lung management protocol. Prog Transplant 2010; 20: 28-32.
40. Noiseux N, Nguyen BK, Marsolais P, et al. Pulmonary recruitment protocol for organ donors: a new strategy to improve the rate of lung utilization. Transplant Proc 2009; 41: 3284-3289.
41. Eberlein M, Permutt S, Chahla MF, et al. Lung size mismatch in bilateral lung transplantation is associated with allograft function and bronchiolitis obliterans syndrome. Chest 2012; 141: 451-460.
42. Eberlein M, Reed RM, Permutt S, et al. Parameters of donor-recipient size mismatch and survival after bilateral lung transplantation. J Heart Lung Transplant 2012; 31: 1207-1213. e7.
43. Borro JM, Sole A, De la Torre M, et al. Steroid withdrawal in lung transplant recipients. Transplant Proc 2005; 37: 3991-3993.
44. Le Page AK, Jager MM, Kotton CN, et al. International survey of cytomegalovirus management in solid organ transplantation after the publication of consensus guidelines. Transplantation 2013; 95: 1455-1460.
45. Paraskeva M, Bailey M, Levvey BJ, et al. Cytomegalovirus replication within the lung allograft is associated with bronchiolitis obliterans syndrome. Am J Transplant 2011; 11: 2190-2196.
46. Westall GP, Cristiano Y, Peleg A, et al. A study of QuantiFERON-CMV-directed CMV prophylaxis versus standard-of-care to reduce late CMV reactivation following lung transplantation. J Heart Lung Transplant 2017; 36: S200-S201.
47. Langer D, Burtin C, Schepers L, et al. Exercise training after lung transplantation improves participation in daily activity: a randomized controlled trial. Am J Transplant 2012; 12: 1584-1592.
48. Ihle F, Neurohr C, Huppmann P, et al. Effect of inpatient rehabilitation on quality of life and exercise capacity in long-term lung transplant survivors: a prospective, randomized study. J Heart Lung Transplant 2011; 30: 912-919.
49. Belloli EA, Wang X, Murray S, et al. Longitudinal forced vital capacity monitoring as a prognostic adjunct after lung transplantation. Am J Respir Crit Care Med 2015; 192: 209-218.
50. Sato M, Waddell TK, Wagnetz U, et al. Restrictive allograft syndrome (RAS): a novel form of chronic lung allograft dysfunction. J Heart Lung Transplant 2011; 30: 735-742.

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Research

Clustered domestic residential aged care in Australia: fewer hospitalisations and better quality of life

Suzanne M Dyer, Enwu Liu, Emmanuel S Gnanamanickam, Rachel Milte, Tiffany Easton, Stephanie L Harrison, Clare E Bradley, Julie Ratcliffe and Maria Crotty

Med J Aust 2018; 208 (10): . || doi: 10.5694/mja17.00861
Published online: 4 June 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Social determinants of health

Gerontology

Health services administration

Abstract

Objective: To compare the outcomes and costs of clustered domestic and standard Australian models of residential aged care.

Design: Cross-sectional retrospective analysis of linked health service data, January 2015 – February 2016.

Setting: 17 aged care facilities in four Australian states providing clustered (four) or standard Australian (13) models of residential aged care.

Participants: People with or without cognitive impairment residing in a residential aged care facility (RACF) for at least 12 months, not in palliative care, with a family member willing to participate on their behalf if required. 901 residents were eligible; 541 consented to participation (24% self-consent, 76% proxy consent).

Main outcome measures: Quality of life (measured with EQ-5D-5L); medical service use; health and residential care costs.

Results: After adjusting for patient- and facility-level factors, individuals residing in clustered models of care had better quality of life (adjusted mean EQ-5D-5L score difference, 0.107; 95% CI, 0.028–0.186; P = 0.008), lower hospitalisation rates (adjusted rate ratio, 0.32; 95% CI, 0.13–0.79; P = 0.010), and lower emergency department presentation rates (adjusted rate ratio, 0.27; 95% CI, 0.14–0.53; P < 0.001) than residents of standard care facilities. Unadjusted facility running costs were similar for the two models, but, after adjusting for resident- and facility-related factors, it was estimated that overall there is a saving of $12 962 (2016 values; 95% CI, $11 092–14 831) per person per year in residential care costs.

Conclusions: Clustered domestic models of residential care are associated with better quality of life and fewer hospitalisations for residents, without increasing whole of system costs.

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1 Flinders University, Adelaide, SA
2 NHMRC Cognitive Decline Partnership Centre, University of Sydney, Sydney, NSW
3 Mary MacKillop Institute for Health Research, Melbourne, VIC
4 Institute for Choice, University of South Australia Business School, Adelaide, SA
5 South Australian Health and Medical Research Institute, Adelaide, SA

Correspondence: sue.dyer@flinders.edu.au

Acknowledgements:

We sincerely thank the INSPIRED study participants and their families for their participation and interest in the study. The assistance of facility staff, careworker researchers, facility pharmacists and data collectors in each state is gratefully acknowledged. We thank members of the study team - Anne Whitehouse, Angela Basso, Keren McKenna, Lua Perimal-Lewis, Wendy Shulver and Rebecca Bilton - for their input into study management, data collection, and data coordination. We acknowledge federal and state data custodians of the datasets used and the respective data linkage organisations, including the federal Departments of Veterans’ Affairs and Human Services, the Centre for Health Record Linkage (NSW Health), the Queensland Health Statistics Unit, the Data and Reporting Services Unit (SA Health, eHealth Systems), and the Western Australian Department of Health Data Linkage Branch.

Competing interests:

No relevant disclosures.

1. Steering Committee for the Review of Government Service Provision. Report on government services 2017. Aged care services. Canberra: Productivity Commission, 2017. http://www.pc.gov.au/research/ongoing/report-on-government-services/2017/community-services/aged-care-services (viewed Jan 2018).
2. Australian Institute of Health and Welfare. Dementia in Australia (AIHW Cat. No. AGE 70). Canberra: AIHW, 2012.
3. Australian Government Department of Health. Why is aged care changing. Updated Nov 2017. https://agedcare.health.gov.au/ageing-and-aged-care-aged-care-reform/why-is-aged-care-changing (viewed Jan 2018).
4. Australian Institute of Health and Welfare. Residential aged care in Australia 2010–11: a statistical overview (AIHW Cat. No. AGE 68; Aged Care Statistics Series No. 36). Canberra: AIHW, 2012.
5. Productivity Commission. Caring for older Australians: overview. Final inquiry report (Report No. 53). 28 June 2011. http://www.pc.gov.au/inquiries/completed/aged-care/report/aged-care-overview-booklet.pdf (viewed Jan 2018).
6. Ausserhofer D, Deschodt M, De Geest S, et al. “There’s no place like home”: a scoping review on the impact of homelike residential care models on resident-, family-, and staff-related outcomes. J Am Med Dir Assoc 2016; 17: 685-693.
7. World Health Organization. World report on ageing and health. Geneva: WHO, 2015. http://apps.who.int/iris/bitstream/10665/186463/1/9789240694811_eng.pdf (viewed Jan 2018).
8. Afendulis CC, Caudry DJ, O’Malley AJ, et al. Green House adoption and nursing home quality. Health Serv Res 2016; 51 Suppl 1: 454-474.
9. Lawton MP. The physical environment of the person with Alzheimer’s disease. Aging Ment Health 2001; 5 Suppl 1: S56-S64.
10. Sharkey SS, Hudak S, Horn SD, et al. Frontline caregiver daily practices: a comparison study of traditional nursing homes and the Green House project sites. J Am Geriatr Soc 2011; 59: 126-131.
11. Gnanamanickam ES, Dyer SM, Milte R, et al. Direct health and residential care costs of people living with dementia in Australian residential aged care. Int J Geriatr Psychiatry 2018; doi:10.1002/gps.4842 [Epub ahead of print].
12. Harrison SL, Kouladjian O’Donnell L, Milte R, et al. Costs of potentially inappropriate medication use in residential aged care facilities. BMC Geriatr 2018; 18: 9.
13. EuroQol. EQ-5D-5L. https://euroqol.org/eq-5d-instruments/eq-5d-5l-about/ (viewed Feb 2018).
14. StewartBrown. Aged care financial performance benchmarks: participant’s kit. Dec 2016. http://www.stewartbrown.com.au/images/documents/2017_Participants_Kit.pdf (viewed Jan 2018).
15. Zimmerman S, Bowers BJ, Cohen LW, et al. New evidence on the Green House model of nursing home care: synthesis of findings and implications for policy, practice, and research. Health Serv Res 2016; 51 Suppl 1: 475-496.
16. Fleming R, Purandare N. Long-term care for people with dementia: environmental design guidelines. Int Psychogeriatr 2010; 22: 1084-1096.
17. Verbeek H, Zwakhalen SM, van Rossum E, et al. Dementia care redesigned: effects of small-scale living facilities on residents, their family caregivers, and staff. J Am Med Dir Assoc 2010; 11: 662-670.
18. Australian Government Department of Health. Manual of resource items and their associated unit costs. The Pharmaceutical Benefits Scheme; Dec 2016. http://www.pbs.gov.au/info/industry/useful-resources/manual (viewed Jan 2018).
19. Easton T, Milte R, Crotty M, Ratcliffe J. Where’s the evidence? a systematic review of economic analyses of residential aged care infrastructure. BMC Health Serv Res 2017; 17: 226.
20. Easton T, Milte R, Crotty M, Ratcliffe J. Advancing aged care: a systematic review of economic evaluations of workforce structures and care processes in a residential care setting. Cost Eff and Resour Alloc 2016; 14: 12.
21. Hounsome N, Orrell M, Edwards RT. EQ-5D as a quality of life measure in people with dementia and their carers: evidence and key issues. Value Health 2011; 14: 390-399.
22. Nakanishi M, Nakashima T, Sawamura K. Quality of life of residents with dementia in a group-living situation: an approach to creating small, homelike environments in traditional nursing homes in Japan. Nihon Koshu Eisei Zasshi 2012; 59: 3-10.
23. te Boekhorst S, Depla MF, de Lange J, et al. The effects of group living homes on older people with dementia: a comparison with traditional nursing home care. Int J Geriatr Psychiatry 2009; 24: 970-978.
24. de Rooij AH, Luijkx KG, Schaafsma J, et al. Quality of life of residents with dementia in traditional versus small-scale long-term care settings: a quasi-experimental study. Int J Nurs Stud 2012; 49: 931-940.
25. Kane RA, Lum TY, Cutler LJ, et al. Resident outcomes in small-house nursing homes: a longitudinal evaluation of the initial green house program. J Am Geriatr Soc 2007; 55: 832-839.
26. Wolf-Ostermann K, Worch A, Fischer T, et al. Health outcomes and quality of life of residents of shared-housing arrangements compared to residents of special care units: results of the Berlin DeWeGE-study. J Clin Nurs 2012; 21: 3047-3060.
27. Grabowski DC, Afendulis CC, Caudry DJ, et al. The impact of Green House adoption on Medicare spending and utilization. Health Serv Res 2016; 51 Suppl 1: 433-453.
28. Grabowski DC, O’Malley AJ, Barhydt NR. The costs and potential savings associated with nursing home hospitalizations. Health Aff (Millwood) 2007; 26: 1753-1761.
29. Jenkens R, Sult T, Lessell N, et al. Financial implications of the Green House model. Seniors and Housing Care Journal 2011; 19: 3-22.

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Editorials

Low risk prostate cancer and an opportunity lost: more activity required in active surveillance

David P Smith and Gary A Wittert

Med J Aust 2018; 208 (10): . || doi: 10.5694/mja18.00209
Published online: 4 June 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Urologic diseases

General medicine

Men's health

Men who are being monitored may be more open to interventions for improving their general health and quality of life

Prostate cancer is the most frequently registered cancer in Australian men, with an estimated 17 729 new diagnoses in 2018.1 For the 25% who are diagnosed with low risk disease, active surveillance (AS) is now the recommended management strategy, as their cancer may never progress.2 Avoiding or at least postponing radical treatment reduces the quality of life risks associated with surgery or radiation therapy. However, there is no evidence-based consensus about the optimal approach to surveillance, and practices differ between countries with regard to the type, frequency, and sequence of follow-up.3 AS differs from “watchful waiting” in that it has a curative intent; watchful waiting involves less intense routine monitoring, intervening only when symptoms appear. One standard approach to AS recommends prostate-specific antigen (PSA) assessment every 3–6 months, a digital rectal examination at least once a year, and at least one biopsy within 12 months of diagnosis, followed by serial biopsy every 2–5 years.

1 Cancer Council NSW, Sydney, NSW
2 University of Adelaide, Adelaide, SA
3 Royal Adelaide Hospital, Adelaide, SA

Correspondence: dsmith@nswcc.org.au

Acknowledgements:

David Smith and Gary Wittert are collaborators on an NHMRC Centre for Research Excellence in Prostate Cancer Survivorship (CRE-PCS) (1116334). David Smith was supported by a grant from Cancer Institute NSW (15/CDF/1‑10).

Competing interests:

David Smith is a member of the Prostate Cancer Outcomes Registry Australia and New Zealand (PCOR-ANZ) steering committee. Gary Wittert is Independent Chair of the Weight Management Council of Australia and has received research support from Weight Watchers.

1. Australian Institute of Health and Welfare. Cancer in Australia 2017 (AIHW Cat. No. CAN 100). Canberra: AIHW, 2017.
2. Chen RC, Rumble RB, Loblaw DA, et al. Active surveillance for the management of localized prostate cancer (Cancer Care Ontario Guideline): American Society of Clinical Oncology clinical practice guideline endorsement. J Clin Oncol 2016; 34: 2182-2190.
3. Ganz PA, Barry JM, Burke W, et al. National Institutes of Health State-of-the-Science Conference: role of active surveillance in the management of men with localized prostate cancer. Ann Intern Med 2012; 156: 591-595.
4. Evans MA, Millar JL, Earnest A, et al. Active surveillance of men with low risk prostate cancer: evidence from the Prostate Cancer Outcomes Registry–Victoria. Med J Aust 2018; 208: 439-443.
5. Egger SJ, Calopedos RJ, O’Connell DL, et al. Long-term psychological and quality-of-life effects of active surveillance and watchful waiting after diagnosis of low-risk localised prostate cancer. Eur Urol 2017; doi:10.1016/j.eururo.2017.08.013. [Epub ahead of print]
6. Sutton E, Hackshaw-McGeagh LE, Aning J, et al. The provision of dietary and physical activity advice for men diagnosed with prostate cancer: a qualitative study of the experiences and views of health care professionals, patients and partners. Cancer Causes Control 2017; 28: 319-329.
7. Daubenmier JJ, Weidner G, Marlin R, et al. Lifestyle and health-related quality of life of men with prostate cancer managed with active surveillance. Urology 2006; 67: 125-130.
8. Farris MS, Courneya KS, Kopciuk KA, et al. Post-diagnosis alcohol intake and prostate cancer survival: a population-based cohort study. Int J Cancer 2018; doi:10.1002/ijc.31307. [Epub ahead of print]
9. Peisch SF, Van Blarigan EL, Chan JM, et al. Prostate cancer progression and mortality: a review of diet and lifestyle factors. World J Urol 2017; 35: 867-874.
10. Adams R, Appleton S, Taylor A, et al. Are the ICSD-3 criteria for sleep apnoea syndrome too inclusive? Lancet Respir Med 2016; 4: e19-e20.
11. Emery JD, Shaw K, Williams B, et al. The role of primary care in early detection and follow-up of cancer. Nat Rev Clin Oncol 2014; 11: 38-48.

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Perspectives

Beyond PSA testing for prostate cancer

Doug Brooks, Ian N Olver and Adrian J Esterman

Med J Aust 2018; 208 (10): . || doi: 10.5694/mja18.00324
Published online: 4 June 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Men's health

Neoplasms

Diagnostic techniques and procedures

Anatomy and physiology

Better biomarkers are needed to ensure early and accurate detection and prognosis of prostate cancer

Prostate cancer is now the most common cancer diagnosed in men in Australia,1 and Australia has one of the highest incidence rates of prostate cancer in the world, with an estimated age-standardised rate of 119.2 per 100 000 men.2 Before 1960, the primary diagnostic test for prostate cancer was the prostatic acid phosphatase test. This was eventually replaced in the 1980s by the prostate-specific antigen (PSA) test.

1 University of South Australia Cancer Research Institute, Adelaide, SA
2 Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD

Correspondence: Doug.Brooks@unisa.edu.au

Competing interests:

Doug Brooks is developing cancer biomarkers for commercialisation with Envision Sciences Pty Ltd.

1. Australian Institute of Health and Welfare. Cancer in Australia 2017 (AIHW Cat. No. CAN 100; Cancer Series No. 101). Canberra: AIHW, 2017. https://www.aihw.gov.au/reports/cancer/cancer-in-australia-2017/contents/table-of-contents (viewed Mar 2018).
2. International Agency for Research on Cancer. GLOBOCAN 2012: estimated cancer incidence and mortality worldwide in 2012. http://globocan.iarc.fr (viewed Mar 2018).
3. Flocks RH, Urich VC, Patel CA, Opitz JM. Studies on the antigenic properties of prostatic tissue. 1. J Urol 1960; 84: 134-143.
4. Wang MC, Papsidero LD, Kuriyama M, et al. Prostate antigen: a new potential marker for prostatic cancer. Prostate 1981; 2: 89-96.
5. Kuriyama M, Wang MC, Lee CI, et al. Use of human prostate-specific antigen in monitoring prostate cancer. Cancer Res 1981; 41: 3874-3876.
6. Medscape. PSA test is misused, unreliable, says the antigen’s discoverer. Medscape Aug 08, 2014. https://www.medscape.com/viewarticle/828854 (viewed March 2018).
7. Harvey P, Basuita A, Endersby D, et al. A systematic review of the diagnostic accuracy of prostate-specific antigen. BMC Urol 2009; 9: 14.
8. Roddam AW, Duffy MJ, Hamdy FC, et al. Use of prostate-specific antigen (PSA) isoforms for the detection of prostate cancer in men with a PSA level of 2-10 ng/ml: systematic review and meta-analysis. Eur Urol 2005; 48: 386-399.
9. Thompson IM, Pauler DK, Goodman PJ, et al. Prevalence of prostate cancer among men with a prostate-specific antigen level ≤4.0 ng per milliliter. N Engl J Med 2004; 350: 2239-2246.
10. Catalona WJ, Richie JP, Goodman PJ, et al. Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicentre clinical trial of 6,630 men. J Urol 1994; 151: 1283-1290.
11. Pinsky PF, Porok PC, Yu K, et al. Extended mortality results for prostate cancer screening in the PLCO trial with a median 15 years follow-up. Cancer 2017; 123: 592-599.
12. Schröder FH, Hugosson J, Roobol MJ, et al. Screening and prostate cancer mortality: results of the European randomised study of screening for prostate cancer (ERSPC) investigators. Lancet 2014; 384: 2072-2035.
13. Tsodikov A, Gulati R, Heijnsdijk, et al. Reconciling the effects of screening on prostate cancer mortality in the ERSPC and PLCO Trials. Ann Intern Med 2017; 167: 449-455.
14. Australian Government Department of Health Standing Committee on Screening. Prostate cancer screening. http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/prostate-cancer-screening? (viewed Apr 2018).
15. Olver I, Brooks DA, Esterman A. Cancer biomarkers in Australia. Adelaide: University of South Australia, 2017. http://www.unisa.edu.au/Global/Health/Research/Cancer%20Biomarkers%20in%20Australia%20Report.pdf (viewed Mar 2018).
16. Pal RP, Kockelbergh RC, Pringle JH, et al. Immunocytochemical detection of ERG expression in exfoliated urinary cells identifies with high specificity patients with prostate cancer. BJU Int 2016; 117: 686-696.
17. Eklund M, Nordström T, Aly M, et al. The Stockholm-3 (STHLM3) model can improve prostate cancer diagnostics in men aged 50-69 yr compared with current prostate cancer testing. Eur Urol Focus 2016; doi:10.1016/j.eurf.2016.10.009 [Epub ahead of print].
18. Hille C, Pantel K. Prostate cancer: circulating tumour cells in prostate cancer. Nat Rev Urol 2018; doi:10.1038/nrurol.2018.25 [Epub ahead of print].
19. Johnson IRD, Parkinson-Lawrence EJ, Keegan H, et al. Endosomal gene expression: an important new indicator for prostate cancer patient prognosis? Oncotarget 2015; 6: 37919-37929.

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Research

Active surveillance of men with low risk prostate cancer: evidence from the Prostate Cancer Outcomes Registry–Victoria

Melanie A Evans, Jeremy L Millar, Arul Earnest, Mark Frydenberg, Ian D Davis, Declan G Murphy, Paul Aidan Kearns and Sue M Evans

Med J Aust 2018; 208 (10): . || doi: 10.5694/mja17.00559
Published online: 28 May 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Environment and public health

Health services administration

Men's health

Neoplasms

Abstract

Objective: To characterise the practice of active surveillance (AS) for men with low risk prostate cancer by examining the characteristics of those who commence AS, the rate of adherence to accepted AS follow-up protocols over 2 years, and factors associated with good adherence.

Design, setting: Retrospective cohort study; analysis of data collected from 38 sites participating in the Prostate Cancer Outcomes Registry–Victoria.

Participants: Men diagnosed with prostate cancer between August 2008 and December 2014 aged 75 years or less at diagnosis, managed by AS for at least 2 years, and with an ISUP grade group of 3 or less (Gleason score no worse than 4 + 3 = 7).

Main outcome measures: Adherence to an AS schedule consisting of at least three PSA measurements and at least one biopsy in the 2 years following diagnosis.

Results: Of 1635 men eligible for inclusion in the analysis, 433 (26.5%) adhered to the AS protocol. The significant predictor of adherence in the multivariate model was being diagnosed in a private hospital (v public hospital: adjusted odds ratio [aOR], 1.83; 95% CI, 1.42–2.37; P < 0.001). Significant predictors of non-adherence included being diagnosed by transurethral resection of the prostate (v transrectal ultrasound biopsy [TRUS]: OR, 0.54; 95% CI, 0.39–0.77; P < 0.001) or transperineal biopsy (v TRUS: OR, 0.32; 95% CI, 0.19–0.52; P < 0.001), and being 66 years of age or more at diagnosis (v < 55 years: OR, 0.65; 95% CI, 0.45–0.92; P = 0.015).

Conclusion: Almost three-quarters of men who had prostate cancer with low risk of disease progression did not have follow-up investigations consistent with standard AS protocols. The clinical consequences of this shortcoming are unknown.

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1 Monash University, Melbourne, VIC
2 Alfred Health, Melbourne, VIC
3 Monash Health, Melbourne, VIC
4 Eastern Health Clinical School, Monash University, Melbourne, VIC
5 The Peter MacCallum Cancer Centre, Melbourne, VIC
6 University of Melbourne, Melbourne, VIC
7 Barwon Health, Geelong, VIC
8 Geelong Urology, Geelong, VIC

Correspondence: sue.evans@monash.edu

Acknowledgements:

Funding for this project has been provided by the Movember Foundation. Ian Davis is supported by a National Health and Medical Research Council Practitioner Fellowship (APP1102604). Sue Evans is supported by a Monash Partners Academic Health Science Centre Fellowship.

Competing interests:

No relevant disclosures.

1. Bul M, Zhu X, Valdagni R, et al. Active surveillance for low-risk prostate cancer worldwide: the PRIAS study. Eur Urol 2013; 63: 597-603.
2. Prostate Cancer Foundation of Australia; Cancer Council Australia PSA Testing Guidelines Expert Advisory Panel. PSA testing and early management of test-detected prostate cancer: active surveillance (Clinical practice guidelines). Jan 2016. http://wiki.cancer.org.au/australiawiki/index.php?oldid=122836 (viewed March 2017).
3. Dall'Era MA, Cooperberg MR, Chan JM, et al. Active surveillance for early-stage prostate cancer: review of the current literature. Cancer 2008; 112: 1650-1659.
4. National Institute for Health and Clinical Excellence. Prostate cancer: diagnosis and management (CG175). Jan 2014. http://www.nice.org.uk/guidance/cg175/resources/prostate-cancer-diagnosis-andmanagement-35109753913285 (viewed Feb 2017).
5. Prostate Cancer Research International: Active Surveillance (PRIAS). Guideline and study for the expectant management of localized prostate cancer with curative intent: study protocol. Nov 2014. https://www.prias-project.org/uploads/pdfs/2014-11-27%20Protocol%20versie%205.0%20(FINAL).pdf (viewed March 2017).
6. Mottet N, Bellmunt J, Briers E, et al. EAU/ESTRO/SIOG guidelines on prostate cancer. European Association of Urology, 2016. https://uroweb.org/wp-content/uploads/EAU-Guidelines-Prostate-Cancer-2016.pdf (viewed Feb 2017).
7. National Comprehensive Cancer Network. Prostate cancer (NCCN clinical practice guidelines in oncology). Version 3.2016. May 2016. https://www.tri-kobe.org/nccn/guideline/urological/english/prostate.pdf (viewed Feb 2017).
8. Klotz L. Active surveillance for men with low-risk, clinically localized prostate cancer. UpToDate; Aug 2016. http://www.uptodate.com/contents/active-surveillance-for-men-with-low-risk-clinically-localized-prostate-cancer#H12016 (viewed Feb 2017).
9. Cheng JY. The Prostate Cancer Intervention Versus Observation Trial (PIVOT) in perspective. J Clin Med Res 2013; 5: 266-268.
10. Hamdy FC, Donovan JL, Neal DE. 10-Year outcomes in localized prostate cancer. N Engl J Med 2017; 376: 180.
11. Wilt TJ, Brawer MK, Jones KM, et al. Radical prostatectomy versus observation for localized prostate cancer. N Engl J Med 2012; 367: 203-213.
12. Evans SM, Millar JL, Wood JM, et al. The Prostate Cancer Registry: monitoring patterns and quality of care for men diagnosed with prostate cancer. BJU Int 2013; 111: E158-E166.
13. Sampurno F, Earnest A, Kumari PB, et al. Quality of care achievements of the Prostate Cancer Outcomes Registry–Victoria. Med J Aust 2016; 204: 319. <MJA full text>
14. Womble PR, Montie JE, Ye ZJ, et al. Contemporary use of initial active surveillance among men in Michigan with low-risk prostate cancer. Eur Urol 2015; 67: 44-50.
15. Cooperberg MR, Carroll PR. Trends in management for patients with localized prostate cancer, 1990–2013. JAMA 2015; 314: 80-82.
16. Loeb S, Folkvaljon Y, Curnyn C, et al. Uptake of active surveillance for very-low-risk prostate cancer in Sweden. JAMA Oncol 2016; Oct 20: 1393-1398.
17. Luckenbaugh AN, Auffenberg GB, Hawken SR, et al. Variation in guideline concordant active surveillance followup in diverse urology practices. J Urol 2017; 197: 621-626.
18. Bokhorst LP, Alberts AR, Rannikko A, et al. Compliance rates with the Prostate Cancer Research International Active Surveillance (PRIAS) protocol and disease reclassification in noncompliers. Eur Urol 2015; 68: 814-821.
19. Loeb S, Walter D, Curnyn C, et al. How active is active surveillance? Intensity of followup during active surveillance for prostate cancer in the United States. J Urol 2016; 196: 721-726.
20. Kinsella N, Stattin P, Cahill D, et al. Factors influencing men's choice of and adherence to active surveillance for low-risk prostate cancer: a mixed-method systematic review. Eur Urol 2018; doi:10.1016/j.eururo.2018.02.026 [Epub ahead of print].
21. Droz JP, Aapro M, Balducci L, et al. Management of prostate cancer in older patients: updated recommendations of a working group of the International Society of Geriatric Oncology. Lancet Oncol 2014; 15: e404-e414.
22. Vyas L, Acher P, Kinsella J, et al. Indications, results and safety profile of transperineal sector biopsies (TPSB) of the prostate: a single centre experience of 634 cases. BJU Int 2014; 114: 32-37.
23. Schoots IG, Petrides N, Giganti F, et al. Magnetic resonance imaging in active surveillance of prostate cancer: a systematic review. Eur Urol 2015; 67: 627-636.
24. Chapple AB, Ziebland S, Brewster S, McPherson A. Patients’ perceptions of transrectal prostate biopsy: a qualitative study. Eur J Cancer Care (Engl) 2007; 16: 215-221.
25. Roth H, Millar JL, Cheng AC, et al. The state of TRUS biopsy sepsis: readmissions to Victorian hospitals with TRUS biopsy-related infection over 5 year. BJU Int 2015; 116: 49-53.

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Perspectives

Virtual medicine: how virtual reality is easing pain, calming nerves and improving health

Brennan MR Spiegel

Med J Aust 2018; 209 (6): . || doi: 10.5694/mja17.00540
Published online: 21 May 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Information science

Virtual reality is thought to create an immersive distraction that restricts the mind from processing pain

Not so far in the future, doctors might prescribe a virtual beach vacation to calm aches and pains, in lieu of pharmacotherapy. Insurance companies might offer scenic tours of Icelandic fjords to lower blood pressure, instead of doubling up on drugs. Psychiatrists might treat social phobia by inviting patients to a virtual dinner party. Hospitals may immerse children in a fantastical playland while they receive chemotherapy.

Cedars-Sinai Health Services, Los Angeles, CA, United States

Correspondence: Brennan.Spiegel@cshs.org

Acknowledgements:

Support for this work is provided by the Marc and Sheri Rapaport Fund for Digital Health Sciences and Precision Health.

Competing interests:

I have received a research grant, administered by Cedars-Sinai Health Services, from appliedVR (Los Angeles, CA). I have no equity, royalty, board positions or other relevant financial relationships to disclose with appliedVR or any other company with a product or service mentioned in this article.

1. Dascal J, Reid M, IsHak WW, et al. Virtual reality and medical inpatients: a systematic review of randomized, controlled trials. Innov Clin Neurosci 2017; 14: 14-21.
2. Malloy KM, Milling LS. The effectiveness of virtual reality distraction for pain reduction: a systematic review. Clin Psychol Rev 2010; 30: 1011-1018.
3. Hoffman HG, Doctor JN, Patterson DR, et al. Virtual reality as an adjunctive pain control during burn wound care in adolescent patients. Pain 2000; 85: 305-309.
4. Hoffman HG, Garcia-Palacios A, Patterson DR, et al. The effectiveness of virtual reality for dental pain control: a case study. Cyberpsychol Behav 2001; 4: 527-535.
5. Hoffman HG, Patterson DR, Carrougher GJ. Use of virtual reality for adjunctive treatment of adult burn pain during physical therapy: a controlled study. Clin J Pain 2000; 16: 244-250.
6. Hoffman HG, Patterson DR, Carrougher GJ, Sharar SR. Effectiveness of virtual reality-based pain control with multiple treatments. Clin J Pain 2001; 17: 229-235.
7. Rizzo AA, Difede J, Rothbaum BO, et al. VR PTSD exposure therapy results with active duty OIF/OEF combatants. Stud Health Technol Inform 2009; 142: 277-282.
8. Maples-Keller JL, Bunnell BE, Kim SJ, Rothbaum BO. The use of virtual reality technology in the treatment of anxiety and other psychiatric disorders. Harv Rev Psychiatry 2017; 25: 103-113.
9. Maples-Keller JL, Price M, Rauch S, et al. Investigating relationships between PTSD symptom clusters within virtual reality exposure therapy for OEF/OIF veterans. Behav Ther 2017; 48: 147-155.
10. Maples-Keller JL, Yasinski C, Manjin N, Rothbaum BO. Virtual reality-enhanced extinction of phobias and post-traumatic stress. Neurotherapeutics 2017; 14: 554-563.
11. Bordnick PS, Traylor AC, Carter BL, Graap KM. A feasibility study of virtual reality-based coping skills training for nicotine dependence. Res Soc Work Pract 2012; 22: 293-300.
12. Bordnick PS, Traylor A, Copp HL, et al. Assessing reactivity to virtual reality alcohol based cues. Addict Behav 2008; 33: 743-756.
13. Bordnick PS, Graap KM, Copp HL, et al. Virtual reality cue reactivity assessment in cigarette smokers. Cyberpsychol Behav 2005; 8: 487-492.
14. Li A, Montaño Z, Chen VJ, Gold JI. Virtual reality and pain management: current trends and future directions. Pain Manag 2011; 1: 147-157.
15. Carrougher GJ, Hoffman HG, Nakamura D, et al. The effect of virtual reality on pain and range of motion in adults with burn injuries. J Burn Care Res 2009; 30: 785-791.
16. Furman E, Jasinevicius TR, Bissada NF, et al. Virtual reality distraction for pain control during periodontal scaling and root planing procedures. J Am Dent Assoc 2009; 140: 1508-1516.
17. Garrett B, Taverner T, Masinde W, et al. A rapid evidence assessment of immersive virtual reality as an adjunct therapy in acute pain management in clinical practice. Clin J Pain 2014; 30: 1089-1098.
18. Gold JI, Kim SH, Kant AJ, et al. Effectiveness of virtual reality for pediatric pain distraction during i.v. placement. Cyberpsychol Behav 2006; 9: 207-212.
19. Sato K, Fukumori S, Matsusaki T, et al. Nonimmersive virtual reality mirror visual feedback therapy and its application for the treatment of complex regional pain syndrome: an open-label pilot study. Pain Med 2010; 11: 622-629.
20. Sarig-Bahat H, Weiss PL, Laufer Y. Neck pain assessment in a virtual environment. Spine (Phila Pa 1976) 2010; 35: E105-E112.
21. Tashjian VC, Mosadeghi S, Howard AR, et al. Virtual reality for management of pain in hospitalized patients: results of a controlled trial. JMIR Ment Health 2017; 4: e9.
22. McCaul KD, Malott JM. Distraction and coping with pain. Psychol Bull 1984; 95: 516-533.
23. Mosadeghi S, Reid MW, Martinez B, et al. Feasibility of an immersive virtual reality intervention for hospitalized patients: an observational cohort study. JMIR Ment Health 2016; 3: e28.

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Narrative review

Impact of ethnicity on the natural history of Parkinson disease

Anna Sauerbier, Azman Aris, Ee Wei Lim, Kalyan Bhattacharya and K Ray Chaudhuri

Med J Aust 2018; 208 (9): . || doi: 10.5694/mja17.01074
Published online: 21 May 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Nervous system diseases

Global health

Summary

Parkinson disease (PD) affects people of all races and ethnicity worldwide.
PD is a multineurotransmitter and multisystem disorder and our current concept of the natural history of PD has changed considerably over the past decades.
Many aspects of this heterogeneous condition still remain unexplained; one aspect that is poorly studied is the role of ethnicity and manifest motor and non-motor PD.
Some preliminary data suggest that the prodromal risk of developing PD, clinical symptom expression and the experience of living with the condition may vary between different ethnic groups.
Several factors might play a role in the influence of ethnicity on PD, such as pharmacogenetics, sociocultural aspects and environmental exposures.
Increased knowledge on the role of ethnicity in PD may help shed light on the symptom expression and treatment response of PD, address inequalities in health care delivery worldwide and improve the delivery of personalised medicine.

1 Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
2 Parkinson's Foundation Centre of Excellence, King's College Hospital NHS Foundation Trust, London, UK
3 National Neuroscience Institute, Singapore
4 RG Kar Medical College and Hospital, Kolkata, India

Correspondence: annasauerbier@nhs.net

Acknowledgements:

We acknowledge the support of the Movement Disorder Society Non-Motor PD Study Group and the Non-Motor PD Early Career Subgroup, and of the National Institute for Health Research (NIHR) London South Clinical Research Network and the NIHR Biomedical Research Centre. Anna Sauerbier has received funding from Parkinson’s UK and the Kirby Laing Foundation. This article represents independent collaborative research part funded by the NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London.

Competing interests:

No relevant disclosures.

1. Halliday G, Lees A, Stern M. Milestones in Parkinson’s disease–clinical and pathologic features. Mov Disord 2011; 26: 1015-1021.
2. Titova N, Padmakumar C, Lewis SJG, Chaudhuri KR. Parkinson’s: a syndrome rather than a disease? J Neural Transm (Vienna) 2017; 124: 907-914.
3. Khedr EM, Al Attar GS, Kandil MR, et al. Epidemiological study and clinical profile of Parkinson’s disease in the Assiut Governorate, Egypt: a community-based study. Neuroepidemiology 2012; 38: 154-163.
4. Wang SJ, Fuh JL, Teng EL, et al. A door-to-door survey of Parkinson’s disease in a Chinese population in Kinmen. Arch Neurol 1996; 53: 66-71.
5. Chaudhuri KR, Hu MT, Brooks DJ. Atypical parkinsonism in Afro-Caribbean and Indian origin immigrants to the UK. Mov Disord 2000; 15: 18-23.
6. Caparros-Lefebvre D, Elbaz A. Possible relation of atypical parkinsonism in the French West Indies with consumption of tropical plants: a case-control study. Caribbean Parkinsonism Study Group. Lancet 1999; 354: 281-286.
7. Caparros-Lefebvre D, Steele J. Atypical parkinsonism on Guadeloupe, comparison with the parkinsonism-dementia complex of Guam, and environmental toxic hypotheses. Environ Toxicol Pharmacol 2005; 19: 407-413.
8. Aharon-Peretz J, Rosenbaum H, Gershoni-Baruch R. Mutations in the glucocerebrosidase gene and Parkinson’s disease in Ashkenazi Jews. N Engl J Med 2004; 351: 1972-1977.
9. Louis ED, Barnes LF, Ford B, et al. Ethnic differences in essential tremor. Arch Neurol 2000; 57: 723-727.
10. Sharafaddinzadeh N, Moghtaderi A, Majdinasab N, et al. The influence of ethnicity on the characteristics of multiple sclerosis: a local population study between Persians and Arabs. Clin Neurol Neurosurg 2013; 115: 1271-1275.
11. Hardiman O, Al-Chalabi A, Brayne C, et al. The changing picture of amyotrophic lateral sclerosis: lessons from European registers. J Neurol Neurosurg Psychiatry 2017; 88: 557-563.
12. Burchard EG, Ziv E, Coyle N, et al. The importance of race and ethnic background in biomedical research and clinical practice. N Engl J Med 2003; 348: 1170-1175.
13. Bower JH. Understanding Parkinson disease in sub Saharan Africa: a call to action for the international neurologic community. Parkinsonism Relat Disord 2017; 41: 1-2.
14. Erro R, Brigo F, Tamburin S, et al. Nutritional habits, risk, and progression of Parkinson disease. J Neurol 2018; 265: 12-23.
15. de Rijk MC, Tzourio C, Breteler MM, et al. Prevalence of parkinsonism and Parkinson’s disease in Europe: the EUROPARKINSON Collaborative Study. European Community Concerted Action on the Epidemiology of Parkinson’s disease. J Neurol Neurosurg Psychiatry 1997; 62: 10-15.
16. Muangpaisan W, Mathews A, Hori H, Seidel D. A systematic review of the worldwide prevalence and incidence of Parkinson’s disease. J Med Assoc Thai 2011; 94: 749-755.
17. Pringsheim T, Jette N, Frolkis A, Steeves TD. The prevalence of Parkinson’s disease: a systematic review and meta-analysis. Mov Disord 2014; 29: 1583-1590.
18. Kessler II. Epidemiologic studies of Parkinson’s disease. 3. A community-based survey. Am J Epidemiol 1972; 96: 242-254.
19. Seo WK, Koh SB, Kim BJ, et al. Prevalence of Parkinson’s disease in Korea. J Clin Neurosci 2007; 14: 1155-1157.
20. Schrag A, Ben-Shlomo Y, Quinn NP. Cross sectional prevalence survey of idiopathic Parkinson’s disease and parkinsonism in London. BMJ 2000; 321: 21-22.
21. Seijo-Martinez M, Castro del Rio M, Rodríguez Alvarez J, et al. Prevalence of parkinsonism and Parkinson’s disease in the Arosa Island (Spain): a community-based door-to-door survey. J Neurol Sci 2011; 304: 49-54.
22. Okada K, Kobayashi S, Tsunematsu T. Prevalence of Parkinson’s disease in Izumo City, Japan. Gerontology 1990; 36: 340-344.
23. Lanska DJ. The geographic distribution of Parkinson’s disease mortality in the United States. J Neurol Sci 1997; 150: 63-70.
24. Masalha R, Kordysh E, Alpert G, et al. The prevalence of Parkinson’s disease in an Arab population, Wadi Ara, Israel. Isr Med Assoc J 2010; 12: 32-35.
25. Lombard A, Gelfand M. Parkinson’s disease in the African. Centr Afr J Med 1978; 24: 5-8.
26. Mayeux R, Marder K, Cote LJ, et al. The frequency of idiopathic Parkinson’s disease by age, ethnic group, and sex in northern Manhattan, 1988-1993. Am J Epidemiol 1995; 142: 820-827.
27. Moriwaka F, Tashiro K, Itoh K, et al. Prevalence of Parkinson’s disease in Hokkaido, the northernmost island of Japan. Intern Med 1996; 35: 276-279.
28. Jendroska K, Olasode BJ, Daniel SE, et al. Incidental Lewy body disease in black Africans. Lancet 1994; 344: 882-883.
29. Dorsey ER, Constantinescu R, Thompson JP, et al. Projected number of people with Parkinson disease in the most populous nations, 2005 through 2030. Neurology 2007; 68: 384-386.
30. Wright Willis A, Evanoff BA, Lian M, et al. Geographic and ethnic variation in Parkinson disease: a population-based study of US Medicare beneficiaries. Neuroepidemiology 2010; 34: 143-151.
31. Zhang Z-X, Anderson DW, Huang J-B, et al. Prevalence of Parkinson’s disease and related disorders in the elderly population of greater Beijing, China. Mov Disord 2003; 18: 764-772.
32. Zhang L, Nie ZY, Liu Y, et al. The prevalence of PD in a nutritionally deficient rural population in China. Acta Neurol Scand 2005; 112: 29-35.
33. Surathi P, Jhunjhunwala K, Yadav R, Pal PK. Research in Parkinson’s disease in India: a review. Ann Indian Acad Neurol 2016; 19: 9-20.
34. Dotchin C, Walker R. Racial differences in the diagnosis of Parkinson’s disease–not just a North American issue [letter]. Mov Disord 2010; 25: 2255-2256; author reply 6-7.
35. Dahodwala N, Siderowf A, Xie M, et al. Racial differences in the diagnosis of Parkinson’s disease. Mov Disord 2009; 24: 1200-1205.
36. Kontis V, Bennett JE, Mathers CD, et al. Future life expectancy in 35 industrialised countries: projections with a Bayesian model ensemble. Lancet 2017; 389: 1323-1335.
37. Calne DB. Is “Parkinson’s disease” one disease? J Neurol Neurosurg Psychiatry 1989; Suppl: 18-21.
38. Korczyn AD. Parkinson’s disease: one disease entity or many? In: Przuntek H, Müller T, editors. Diagnosis and treatment of Parkinson’s disease — state of the art. Vienna: Springer, 1999; pp 107-111.
39. Langston JW. The Parkinson’s complex: parkinsonism is just the tip of the iceberg. Ann Neurol 2006; 59: 591-596.
40. Hu MT, Chaudhuri KR, Jarosz J, et al. An imaging study of parkinsonism among African-Caribbean and Indian London communities. Mov Disord 2002; 17: 1321-1328.
41. Caparros-Lefebvre D, Sergeant N, Lees A, et al. Guadeloupean parkinsonism: a cluster of progressive supranuclear palsy-like tauopathy. Brain 2002; 125(Pt 4): 801-811.
42. Lannuzel A, Ruberg M, Michel PP. Atypical parkinsonism in the Caribbean island of Guadeloupe: etiological role of the mitochondrial complex I inhibitor annonacin. Mov Disord 2008; 23: 2122-2128.
43. Mulder DW, Kurland LT, Iriarte LL. Neurologic diseases on the island of Guam. U S Armed Forces Med J 1954; 5: 1724-1739.
44. Steele JC. Parkinsonism-dementia complex of Guam. Mov Disord 2005; 20 Suppl 12: S99-S107.
45. Uitti RJ, Berry K, Yasuhara O, et al. Neurodegenerative ‘overlap’ syndrome: clinical and pathological features of Parkinson’s disease, motor neuron disease, and Alzheimer’s disease. Parkinsonism Relat Disord 1995; 1: 21-34.
46. Zhang ZX, Anderson DW, Lavine L, Mantel N. Patterns of acquiring parkinsonism-dementia complex on Guam. 1944 through 1985. Arch Neurol 1990; 47: 1019-1024.
47. Kuzuhara S. [ALS and parkinsonism-dementia complex of Kii peninsula] [Japanese]. Ryoikibetsu Shokogun Shirizu 1999(27 Pt 2): 335-338.
48. Okumiya K, Wada T, Fujisawa M, et al. Amyotrophic lateral sclerosis and parkinsonism in Papua, Indonesia: 2001-2012 survey results. BMJ Open 2014; 4: e004353.
49. Caparros-Lefebvre D, Steele J, Kotake Y, Ohta S. Geographic isolates of atypical Parkinsonism and tauopathy in the tropics: possible synergy of neurotoxins. Mov Disord 2006; 21: 1769-1771.
50. Angibaud G, Gaultier C, Rascol O. Atypical parkinsonism and Annonaceae consumption in New Caledonia. Mov Disord 2004; 19: 603-604.
51. de Bie RM, Gladstone RM, Strafella AP, et al Manganese-induced Parkinsonism associated with methcathinone (Ephedrone) abuse. Arch Neurol 2007; 64: 886-889.
52. Chaudhuri KR, Martinez-Martin P, Brown RG, et al. The metric properties of a novel non-motor symptoms scale for Parkinson’s disease: Results from an international pilot study. Mov Disord 2007; 22: 1901-1911.
53. Sauerbier A, Jitkritsadakul O, Titova N, et al. Non-motor symptoms assessed by Non-Motor Symptoms Questionnaire and Non-Motor Symptoms Scale in Parkinson’s disease in selected Asian populations. Neuroepidemiology 2017; 49: 1-17.
54. Barone P, Antonini A, Colosimo C, et al. The PRIAMO study: a multicenter assessment of nonmotor symptoms and their impact on quality of life in Parkinson’s disease. Mov Disord 2009; 24: 1641-1649.
55. Cheon SM, Ha MS, Park MJ, Kim JW. Nonmotor symptoms of Parkinson’s disease: prevalence and awareness of patients and families. Parkinsonism Relat Disord 2008; 14: 286-290.
56. Maïga B, Koné A, Landouré G, et al. Non-motor signs in patients with Parkinson’s disease at the University Hospital of Point “G”, Mali. eNeurologicalSci 2016; 3: 35-36.
57. Wang G, Hong Z, Cheng Q, et al. Validation of the Chinese non-motor symptoms scale for Parkinson’s disease: results from a Chinese pilot study. Clin Neurol Neurosurg 2009; 111: 523-526.
58. Hoehn MM, Yahr MD. Parkinsonism: onset, progression and mortality. Neurology 1967; 17: 427-442.
59. Li H, Zhang M, Chen L, et al. Nonmotor symptoms are independently associated with impaired health-related quality of life in Chinese patients with Parkinson’s disease. Mov Disord 2010; 25: 2740-2746.
60. Sellami L, Kacem I, Nasri A, et al. Evaluation of an Arabic version of the non-motor symptoms scale in Parkinson’s disease. Neurol Sci 2016; 37: 963-968.
61. Branson CO, Ferree A, Hohler AD, Saint-Hilaire M-H. Racial disparities in Parkinson disease: a systematic review of the literature. Adv Parkinsons Dis 2016; 5: 87-96.
62. Chan JC, Malik V, Jia W, et al. Diabetes in Asia: epidemiology, risk factors, and pathophysiology. JAMA 2009; 301: 2129-2140.
63. Mischley LK, Lau RC, Bennett RD. Role of diet and nutritional supplements in Parkinson's disease progression. Oxid Med Cell Longev 2017; 2017: 6405278.
64. Alcalay RN, Gu Y, Mejia-Santana H, et al. The association between Mediterranean diet adherence and Parkinson’s disease. Mov Disord 2012; 27: 771-774.
65. Ho SC, Woo J, Lee CM. Epidemiologic study of Parkinson’s disease in Hong Kong. Neurology 1989; 39: 1314-1318.
66. Pan S, Stutzbach J, Reichwein S, et al. Knowledge and attitudes about Parkinson’s disease among a diverse group of older adults. J Cross Cult Gerontol 2014; 29: 339-352.
67. National Research Council Panel on Race, EHealth in Later Life The National Academies Collection: Reports funded by National Institutes of Health. In: Anderson NB, Bulatao RA, Cohen B, editors. Critical perspectives on racial and ethnic differences in health in late life. Washington (DC): National Academies Press (US), 2004.
68. Huang T, Shu Y, Cai Y-D. Genetic differences among ethnic groups. BMC Genomics 2015; 16: 1093.
69. Fung HC, Chen CM, Hardy J, et al. A common genetic factor for Parkinson disease in ethnic Chinese population in Taiwan. BMC Neurol 2006; 6: 47.
70. Gopalai AA, Lim SY, Chua JY, et al. LRRK2 G2385R and R1628P mutations are associated with an increased risk of Parkinson’s disease in the Malaysian population. Biomed Res Int 2014; 2014: 867321.
71. Inzelberg R, Hassin-Baer S, Jankovic J. Genetic movement disorders in patients of Jewish ancestry. JAMA Neurol 2014; 71: 1567-1572.
72. Huang CL, Wu-Chou YH, Lai SC, et al. Contribution of glucocerebrosidase mutation in a large cohort of sporadic Parkinson’s disease in Taiwan. Eur J Neurol 2011; 18: 1227-1232.
73. Barkhuizen M, Anderson DG, Grobler AF. Advances in GBA-associated Parkinson’s disease–Pathology, presentation and therapies. Neurochem Int 2016; 93: 6-25.
74. Alcalay RN, Mirelman A, Saunders-Pullman R, et al. Parkinson disease phenotype in Ashkenazi Jews with and without LRRK2 G2019S mutations. Mov Disord 2013; 28: 1966-1971.
75. Brockmann K, Srulijes K, Pflederer S, et al. GBA-associated Parkinson’s disease: reduced survival and more rapid progression in a prospective longitudinal study. Mov Disord 2015; 30: 407-411.
76. McLeod HL, Syvanen AC, Githang’a J, et al. Ethnic differences in catechol O-methyltransferase pharmacogenetics: frequency of the codon 108/158 low activity allele is lower in Kenyan than Caucasian or South-west Asian individuals. Pharmacogenetics 1998; 8: 195-199.
77. Dotchin C, Walker R. The management of Parkinson’s disease in sub-Saharan Africa. Expert Rev Neurother 2012; 12: 661-666.
78. Hemming JP, Gruber-Baldini AL, Anderson KE, et al. Racial and socioeconomic disparities in parkinsonism. Arch Neurol 2011; 68: 498-503.
79. Lewey J, Choudhry NK. The current state of ethnic and racial disparities in cardiovascular care: lessons from the past and opportunities for the future. Curr Cardiol Rep 2014; 16: 530.
80. Nagashayana N, Sankarankutty P, Nampoothiri MR, et al. Association of L-DOPA with recovery following Ayurveda medication in Parkinson’s disease. J Neurol Sci 2000; 176: 124-127.
81. Sauerbier A, Lenka A, Aris A, Pal PK. Nonmotor symptoms in Parkinson's disease: gender and ethnic differences. Int Rev Neurobiol 2017; 133: 417-446.
82. Rana AQ, Athar A, Owlia A, et al. Impact of ethnicity on non-motor symptoms of Parkinson’s disease. J Parkinsons Dis 2012; 2: 281-285.
83. Titova N, Chaudhuri KR. Personalized medicine in Parkinson’s disease: time to be precise. Mov Disord 2017; 32: 1147-1154.

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Narrative review

Non-motor Parkinson disease: new concepts and personalised management

Nataliya Titova and K Ray Chaudhuri

Med J Aust 2018; 208 (9): . || doi: 10.5694/mja17.00993
Published online: 21 May 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Nervous system diseases

Social determinants of health

Diagnostic techniques and procedures

Summary

Most patients with Parkinson disease (PD) have non-motor symptoms (NMS), and on average these can range from four to 19 different symptoms.
NMS dominate the prodromal phase of PD and some may serve as clinical biomarkers of PD.
NMS can be dopaminergic, non-dopaminergic, of genetic origin or drug induced.
Clinical assessment of NMS should include the NMS Questionnaire (completed by patients) for screening, as recommended by the International Parkinson and Movement Disorders Society and other international societies.
The total number of NMS in a patient with PD constitutes the NMS burden, which can be graded using validated cut-off scores on the NMS Questionnaire and Scale and can be used as an outcome measure in clinical trials.
Despite NMS burden having a major effect on the quality of life of patients and carers, a large European study showed that NMS are often ignored in the clinic.
The syndromic nature of PD is underpinned by non-motor subtypes which are likely to be related to specific dysfunction of cholinergic, noradrenergic, serotonergic pathways in the brain, not just the dopaminergic pathways.
NMS can be treated by dopaminergic and non-dopaminergic strategies, but further robust studies supported by evidence from animal models are required.
The future of modern treatment of PD needs to be supported by the delivery of personalised medicine.

1 Pirogov Russian National Research Medical University, Moscow, Russia
2 Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK

Correspondence: nattitova@yandex.ru

Acknowledgements:

We thank the National Institute of Health Research Biomedical Research Centre and the Institute of Psychiatry, Psychology and Neuroscience at Kings College London for supporting research cited in this article, and the MDS Non-Motor Parkinson’s Disease Study Group.

Competing interests:

No relevant disclosures.

1. Parkinson J. An essay on the shaking palsy. Lond Med Phys J 1817; 38.
2. Korczyn AD. Parkinson’s disease: one disease entity or many? J Neural Transm 1999; 56: 107-111.
3. Langston JW. The Parkinson’s complex: parkinsonism is just the tip of the iceberg. Ann Neurol 2006; 59: 591-596.
4. Titova N, Padmakumar C, Lewis SJG, et al. Parkinson’s: a syndrome rather than a disease? J Neural Transm (Vienna) 2017; 124: 907-914.
5. Chaudhuri, KR, Healy DG, Schapira AHV. Non-motor symptoms of Parkinson’s disease: diagnosis and management. Lancet Neurol 2006; 5: 235-245.
6. Martinez-Martin P, Rodriguez-Blazquez C, Kurtis MM, NMSS Validation Group. The impact of non-motor symptoms on health-related quality of life of patients with Parkinson’s disease. Mov Disord 2011; 26: 399-406.
7. Chaudhuri KR, Rojo JM, Schapira AHV, et al. A proposal for a comprehensive grading of Parkinson’s disease severity combining motor and non-motor assessments: meeting an unmet need. PLoS One 2013; 8: e57221.
8. Chaudhuri KR, Sauerbier A, Rojo J, et al. The burden of non-motor symptoms in Parkinson’s disease using a self-completed non-motor questionnaire: a simple grading system. Parkinsonism Relat Disord 2015; 21: 287-291.
9. Titova N, Chaudhuri KR. Personalized medicine in Parkinson’s disease: time to be precise. Mov Disord 2017; 32: 1147-1154.
10. Alves G, Forsaa E, Pedersen KF, et al. Epidemiology of Parkinson’s disease. J Neurol 2008; 255(Suppl 5): 18-32.
11. Titova N, Qamar MA, Chaudhuri KR. Biomarkers of Parkinson’s disease: an introduction. Int Rev Neurobiol 2017; 132: 183-196.
12. Chaudhuri KR, Odin P. The challenge of non-motor symptoms in Parkinson’s disease. Prog Brain Res 2010; 184: 325-341.
13. Berg D, Postuma RB, Adler CH, et al. MDS research criteria for prodromal Parkinson’s disease. Mov Disord 2015; 30: 1600-1611.
14. Doppler K, Jentschke HM, Schulmeyer L, et al. Dermal phospho-alpha-synuclein deposits confirm REM sleep behaviour disorder as prodromal Parkinson’s disease. Acta Neuropathol 2017; 133: 535-545.
15. Katunina E, Titova N. The epidemiology of nonmotor symptoms in Parkinson’s disease (cohort and other studies). Int Rev Neurobiol 2017; 133: 91-110.
16. Todorova A, Jenner P, Chaudhuri KR. Non-motor Parkinson’s: integral to motor Parkinson’s, yet often neglected. Pract Neurol 2014; 14: 310-322.
17. Barone P, Antonini A, Colosimo C, et al. The PRIAMO study: a multicenter assessment of nonmotor symptoms and their impact on quality of life in Parkinson’s disease. Mov Disord 2009; 24: 1641-1649.
18. Jankovic J. Parkinson’s disease: clinical features and diagnosis. J Neurol Neurosurg Psychiatry 2008; 79: 368-376.
19. Martinez-Martin P, Rodriguez-Blazquez C, Abe K, et al. International study on the psychometric attributes of the non-motor symptoms scale in Parkinson disease. Neurology 2009; 73: 1584-1591.
20. Schrag A, Jahanshahi M, Quinn N. What contributes to quality of life in patients with Parkinson’s disease? J Neurol Neurosurg Psychiatry 2000; 69: 308-312.
21. Hagell P, Nordling S, Reimer J, et al. Resource use and costs in a Swedish cohort of patients with Parkinson’s disease. Mov Disord 2002; 17: 1213-1220.
22. Braak H, Del Tredici K, Rub U, et al. Staging of brain pathology related to sporadic Parkinson’s disease. Neurobiol Aging 2003; 24: 197-211.
23. Braak H, Ghebremedhin E, Rub U, et al. Stages in the development of Parkinson’s disease-related pathology. Cell Tissue Res 2004; 318: 121-134.
24. Postuma RB, Iranzo A, Hogl B, et al. Risk factors for neurodegeneration in idiopathic rapid eye movement sleep behavior disorder: a multicenter study. Ann Neurol 2015; 77: 830-839.
25. Hassan A, Wu SS, Schmidt P, et al. The profile of long-term Parkinson’s disease survivors with 20 years of disease duration and beyond. J Parkinsons Dis 2015; 5: 313-319.
26. Titova N, Martinez-Martin P, Katunina E, et al. Advanced Parkinson’s or “complex phase” Parkinson’s disease? Re-evaluation is needed. J Neural Transm 2017; 124: 1529-1537.
27. Jellinger KA. Neuropathobiology of non-motor symptoms in Parkinson disease. J Neural Transm (Vienna) 2015; 122: 1429-1440.
28. Jellinger KA. Neuropathology of sporadic Parkinson's disease: evaluation and changes of concepts. Mov Disord 2012; 27: 8-30.
29. Titova N, Schapira AHV, Chaudhuri KR, et al. Nonmotor symptoms in experimental models of Parkinson’s disease. Int Rev Neurobiol 2017; 133: 63-89.
30. Chaudhuri KR, Martinez-Martin P, Schapira AHV, et al. International multicenter pilot study of the first comprehensive self-completed nonmotor symptoms questionnaire for Parkinson’s disease: the NMSQuest study. Mov Disord 2006; 21: 916-923.
31. Chaudhuri KR, Martinez-Martin P, Brown RG, et al. The metric properties of a novel non-motor symptoms scale for Parkinson’s disease: results from an international pilot study. Mov Disord 2007; 22: 1901-1911.
32. Martinez-Martin P, Chaudhuri KR, Rojo-Abuin JM, et al. Assessing the non-motor symptoms of Parkinson’s disease: MDS-UPDRS and NMS Scale. Eur J Neurol 2015; 22: 37-43.
33. Titova NV, Chaudhuri KR. Non-motor symptoms of Parkinson’s disease: the submerged part of the iceberg. Ann Clin Exp Neurol 2017; 11(4): 5-18.
34. Sauerbier A, Qamar MA, Rajah T, et al. New concepts in the pathogenesis and presentation of Parkinson’s disease. Clin Med (Lond) 2016; 16: 365-370.
35. Martinez-Martin P, Ray Chaudhuri K. Comprehensive grading of Parkinson’s disease using motor and non-motor assessments: addressing a key unmet need. Expert Rev Neurother 2018; 18: 41-50.
36. Storch A, Schneider CB, Wolz M, et al. Nonmotor fluctuations in Parkinson disease: severity and correlation with motor complications. Neurology 2013; 80: 800-809.
37. Erro R, Vitale C, Amboni M, et al. The heterogeneity of early Parkinson’s disease: a cluster analysis on newly diagnosed untreated patients. PLoS One 2013; 8: e70244.
38. Pont-Sunyer C, Hotter A, Gaig C, et al. The onset of nonmotor symptoms in Parkinson’s disease (the ONSET PD study). Mov Disord 2015: 30; 229-237.
39. Sauerbier A, Jenner P, Todorova A, et al. Non motor subtypes and Parkinson’s disease. Parkinsonism Relat Disord 2016; 22(Suppl 1): 41-46.
40. Zis P, Martinez-Martin P, Sauerbier A, et al. Non-motor symptoms burden in treated and untreated early Parkinson’s disease patients: argument for non-motor subtypes. Eur J Neurol 2015; 22: 1145-1150.
41. Marras C, Chaudhuri KR. Nonmotor features of Parkinson’s disease subtypes. Mov Disord 2016; 31: 1095-1102.
42. Williams-Gray CH, Evans JR, Goris A, et al. The distinct cognitive syndromes of Parkinson’s disease: 5 year follow-up of the CamPaIGN cohort. Brain 2009; 132(Pt 11): 2958-2969.
43. Weintraub D, Simuni T, Caspell-Garcia C, et al.; Parkinson’s Progression Markers Initiative Cognitive performance and neuropsychiatric symptoms in early, untreated Parkinson’s disease. Mov Disord 2015; 30: 919-927.
44. Shimada H, Hirano S, Shinotoh H, et al. Mapping of brain acetylcholinesterase alterations in Lewy body disease by PET. Neurology 2009; 73: 273-278.
45. Gjerløff T, Fedorova T, Knudsen K, et al. Imaging acetylcholinesterase density in peripheral organs in Parkinson’s disease with 11C-donepezil PET. Brain 2015; 138(Pt 3): 653-663.
46. O’Callaghan C, Lewis SJG. Cognition in Parkinson’s disease. Int Rev Neurobiol 2017; 133: 557-583.
47. Muralidharan V, Balasubramani PP, Chakravarthy VS, et al. A neurocomputational model of the effect of cognitive load on freezing of gait in Parkinson’s disease. Front Hum Neurosci 2017; 10: 649.
48. Espay AJ, LeWitt PA, Kaufmann H. Norepinephrine deficiency in Parkinson’s disease: the case for noradrenergic enhancement. Mov Disord 2014; 29: 1710-1719.
49. Pavese N, Metta V, Bose SK, et al. Fatigue in Parkinson’s disease is linked to striatal and limbic serotonergic dysfunction. Brain 2010; 133: 3434-3443.
50. Seppi K, Weintraub D, Coelho M, et al. The Movement Disorder Society Evidence-Based Medicine Review Update: treatments for the non-motor symptoms of Parkinson’s disease. Mov Disord 2011; 26(Suppl 3): S42-80.
51. Schrag A, Sauerbier A, Chaudhuri KR. New clinical trials for nonmotor manifestations of Parkinson’s disease. Mov Disord 2015; 30: 1490-1504.
52. Titova N, Jenner P, Chaudhuri KR. The future of Parkinson’s treatment - personalised and precision medicine. Eur Neurol Rev 2017; 12: 15-16.

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