MJA
MJA

    Screening for spinal muscular atrophy

    Hugo Sampaio, Bridget Wilcken and Michelle Farrar
    Med J Aust 2018; 209 (4): . || doi: 10.5694/mja17.00772
    Published online: 20 August 2018

    Early diagnosis allows the possibility of starting treatment at a young age to achieve better outcomes

    Rapid advances in technology and novel disease-modifying treatments will increase demands for early diagnosis and screening for many severe childhood conditions. This is exemplified by spinal muscular atrophy (SMA).

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      Transcatheter aortic valve implantation: a new standard of care

      Adam J Nelson, Nicholas J Montarello, Claudia S Cosgrove, Ross L Roberts-Thomson, Sinny Delacroix, Ramesh G Chokka, Joseph K Montarello and Stephen G Worthley
      Med J Aust 2018; 209 (3): . || doi: 10.5694/mja17.01255
      Published online: 6 August 2018

      Summary

       

      • Aortic stenosis is the most common valvular lesion requiring intervention and with an ageing population, its burden is likely to increase.
      • Increasing comorbidity and a desire for less invasive treatment strategies has facilitated the expansion of percutaneous aortic valve therapies.
      • Robust clinical trial data are now available to support the role of transcatheter aortic valve implantation (TAVI) in patients of prohibitive, high and now intermediate surgical risk.
      • The introduction of a Medicare Benefits Schedule reimbursement is likely to see TAVI use grow exponentially in Australia over the next 5 years.
      • Clinical trials evaluating low risk patients may be the final frontier to see TAVI become the standard of care for most patients with severe aortic stenosis.

       


      • Royal Adelaide Hospital, Adelaide, SA


      Correspondence: adam.nelson@adelaide.edu.au
      Competing interests:

      Stephen Worthley consults for and has received honoraria from Medtronic and Abbott.

      • 1. Yeh RW, Sidney S, Chandra M, et al. Population trends in the incidence and outcomes of acute myocardial infarction. N Engl J Med 2010; 362: 2155-2165.
      • 2. Nkomo VT, Gardin JM, Skelton TN, et al. Burden of valvular heart diseases: a population-based study. Lancet 2006; 368: 1005-1011.
      • 3. Ross J, Jr., Braunwald E. Aortic stenosis. Circulation 1968; 38: 61-67.
      • 4. Ben-Dor I, Pichard AD, Gonzalez MA, et al. Correlates and causes of death in patients with severe symptomatic aortic stenosis who are not eligible to participate in a clinical trial of transcatheter aortic valve implantation. Circulation 2010; 122: S37-S42.
      • 5. Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2010; 363: 1597-1607.
      • 6. Harken DE, Soroff HS, Taylor WJ, et al. Partial and complete prostheses in aortic insufficiency. J Thorac Cardiovasc Surg 1960; 40: 744-762.
      • 7. Iung B, Cachier A, Baron G, et al. Decision-making in elderly patients with severe aortic stenosis: why are so many denied surgery? Eur Heart J 2005; 26: 2714-2720.
      • 8. Layland JJ, Bell B, Mullany D, Walters DL. Percutaneous management of aortic stenosis in high-risk patients. Med J Aust 2010; 192: 520-525. <MJA full text>
      • 9. Cribier A, Eltchaninoff H, Bash A, et al. Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description. Circulation 2002; 106: 3006-3008.
      • 10. Anderson RP. First publications from the Society of Thoracic Surgeons National Database. Ann Thorac Surg 1994; 57: 6-7.
      • 11. O’Brien SM, Shahian DM, Filardo G, et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 2-isolated valve surgery. Ann Thorac Surg 2009; 88: S23-S42.
      • 12. Kapadia SR, Leon MB, Makkar RR, et al. 5-year outcomes of transcatheter aortic valve replacement compared with standard treatment for patients with inoperable aortic stenosis (PARTNER 1): a randomised controlled trial. Lancet 2015; 385: 2485-2491.
      • 13. Popma JJ, Adams DH, Reardon MJ, et al. Transcatheter aortic valve replacement using a self-expanding bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery. J Am Coll Cardiol 2014; 63: 1972-1981.
      • 14. Kodali S, Thourani VH, White J, et al. Early clinical and echocardiographic outcomes after SAPIEN 3 transcatheter aortic valve replacement in inoperable, high-risk and intermediate-risk patients with aortic stenosis. Eur Heart J 2016; 37: 2252-2262.
      • 15. Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 2011; 364: 2187-2198.
      • 16. Mack MJ, Leon MB, Smith CR, et al. 5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial. Lancet 2015; 385: 2477-2484.
      • 17. Adams DH, Popma JJ, Reardon MJ. Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J Med 2014; 371: 967-968.
      • 18. Reardon MJ, Adams DH, Kleiman NS, et al. 2-year outcomes in patients undergoing surgical or self-expanding transcatheter aortic valve replacement. J Am Coll Cardiol 2015; 66: 113-121.
      • 19. Leon MB, Smith CR, Mack MJ, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med 2016; 374: 1609-1620.
      • 20. Reardon MJ, Van Mieghem NM, Popma JJ, et al. Surgical or transcatheter aortic-valve replacement in intermediate-risk patients. N Engl J Med 2017; 376: 1321-1331.
      • 21. Sondergaard L, Steinbruchel DA, Ihlemann N, et al. Two-year outcomes in patients with severe aortic valve stenosis randomized to transcatheter versus surgical aortic valve replacement: the All-Comers Nordic Aortic Valve Intervention Randomized Clinical Trial. Circ Cardiovasc Interv 2016; 9: e003665.
      • 22. Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 2009; 360: 961-972.
      • 23. Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2017; 135: e1159-e1195.
      • 24. Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J 2017; 38: 2739-2791.
      • 25. Lanken PN, Ahlheit BD, Crawford S, et al. Withholding and withdrawing life-sustaining therapy. Am Rev Respir Dis 1991; 144: 726-731.
      • 26. Schoenenberger AW, Stortecky S, Neumann S, et al. Predictors of functional decline in elderly patients undergoing transcatheter aortic valve implantation (TAVI). Eur Heart J 2013; 34: 684-692.
      • 27. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56: M146-M156.
      • 28. Rodes-Cabau J, Mok M. Working toward a frailty index in transcatheter aortic valve replacement: a major move away from the “eyeball test”. JACC Cardiovasc Interv 2012; 5: 982-983.
      • 29. Kahlert P, Knipp SC, Schlamann M, et al. Silent and apparent cerebral ischemia after percutaneous transfemoral aortic valve implantation: a diffusion-weighted magnetic resonance imaging study. Circulation 2010; 121: 870-878.
      • 30. Nombela-Franco L, Webb JG, de Jaegere PP, et al. Timing, predictive factors, and prognostic value of cerebrovascular events in a large cohort of patients undergoing transcatheter aortic valve implantation. Circulation 2012; 126: 3041-3053.
      • 31. Webb J, Rodes-Cabau J, Fremes S, et al. Transcatheter aortic valve implantation: a Canadian Cardiovascular Society position statement. Can J Cardiol 2012; 28: 520-528.
      • 32. Kahlert P, Al-Rashid F, Dottger P, et al. Cerebral embolization during transcatheter aortic valve implantation: a transcranial Doppler study. Circulation 2012; 126: 1245-1255.
      • 33. Schmidt T, Akdag O, Wohlmuth P, et al. Histological findings and predictors of cerebral debris from transcatheter aortic valve replacement: the ALSTER experience. J Am Heart Assoc 2016; 5: e004399.
      • 34. Bagur R, Solo K, Alghofaili S, et al. Cerebral embolic protection devices during transcatheter aortic valve implantation: systematic review and meta-analysis. Stroke 2017; 48: 1306-1315.
      • 35. Haussig S, Mangner N, Dwyer MG, et al. Effect of a cerebral protection device on brain lesions following transcatheter aortic valve implantation in patients with severe aortic stenosis: the CLEAN-TAVI Randomized Clinical Trial. JAMA 2016; 316: 592-601.
      • 36. Gerckens U, Tamburino C, Bleiziffer S, et al. Final 5-year clinical and echocardiographic results for treatment of severe aortic stenosis with a self-expanding bioprosthesis from the ADVANCE Study. Eur Heart J 2017; 38: 2729-2738.
      • 37. Foroutan F, Guyatt GH, Otto CM, et al. Structural valve deterioration after transcatheter aortic valve implantation. Heart 2017; 103: 1899-1905.
      • 38. Beohar N, Kirtane AJ, Blackstone E, et al. Trends in complications and outcomes of patients undergoing transfemoral transcatheter aortic valve replacement: experience from the PARTNER continued access registry. JACC Cardiovasc Interv 2016; 9: 355-363.
      • 39. Kodali S, Pibarot P, Douglas PS, et al. Paravalvular regurgitation after transcatheter aortic valve replacement with the Edwards sapien valve in the PARTNER trial: characterizing patients and impact on outcomes. Eur Heart J 2015; 36: 449-456.
      • 40. Athappan G, Patvardhan E, Tuzcu EM, et al. Incidence, predictors, and outcomes of aortic regurgitation after transcatheter aortic valve replacement: meta-analysis and systematic review of literature. J Am Coll Cardiol 2013; 61: 1585-1595.
      • 41. Nietlispach F, Maisano F, Sorajja P, Leon MB, Rihal C, Feldman T. Percutaneous paravalvular leak closure: chasing the chameleon. Eur Heart J 2016; 37: 3495-3502.
      • 42. Ussia GP, Barbanti M, Ramondo A, et al. The valve-in-valve technique for treatment of aortic bioprosthesis malposition an analysis of incidence and 1-year clinical outcomes from the Italian CoreValve registry. J Am Coll Cardiol 2011; 57: 1062-1068.
      • 43. Moreno R, Dobarro D, Lopez de Sa E, et al. Cause of complete atrioventricular block after percutaneous aortic valve implantation: insights from a necropsy study. Circulation 2009; 120: e29-e30.
      • 44. Wendler O, Schymik G, Treede H, et al. SOURCE 3 Registry: design and 30-day results of the European postapproval registry of the latest generation of the SAPIEN 3 transcatheter heart valve. Circulation 2017; 135: 1123-1132.
      • 45. Sorajja P, Kodali S, Reardon MJ, et al. Outcomes for the commercial use of self-expanding prostheses in transcatheter aortic valve replacement: a report from the STS/ACC TVT registry. JACC Cardiovasc Interv 2017; 10: 2090-2098.
      • 46. Hoffmann G, Lutter G, Cremer J. Durability of bioprosthetic cardiac valves. Dtsch Arztebl Int 2008; 105: 143-148.
      • 47. Webb JG, Mack MJ, White JM, et al. Transcatheter aortic valve implantation within degenerated aortic surgical bioprostheses: PARTNER 2 Valve-in-Valve Registry. J Am Coll Cardiol 2017; 69: 2253-2262.
      • 48. Puri R, Chamandi C, Rodriguez-Gabella T, Rodes-Cabau J. Future of transcatheter aortic valve implantation - evolving clinical indications. Nat Rev Cardiol 2018; 15: 57-65.
      • 49. Eggebrecht H, Mehta RH. Transcatheter aortic valve implantation (TAVI) in Germany 2008–2014: on its way to standard therapy for aortic valve stenosis in the elderly? EuroIntervention 2016; 11: 1029-1033.
      • 50. Walters DL, Webster M, Pasupati S, et al. Position statement for the operator and institutional requirements for a transcatheter aortic valve implantation (TAVI) program. Heart Lung Circ 2015; 24: 219-223.
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        Why are women with ST-elevation myocardial infarction treated differently to men?

        Andrew I MacIsaac and Gemma Figtree
        Med J Aust 2018; 209 (3): . || doi: 10.5694/mja18.00476
        Published online: 6 August 2018

        STEMI and coronary artery disease are major but underappreciated killers of Australian women

        This issue of the Journal includes confronting data about inequities in the treatment and outcomes for men and women with ST-elevation myocardial infarction (STEMI). Khan and colleagues report that the 6-month mortality for women presenting with STEMI is twice that of men, a difference that persists after statistical correction for age and comorbid conditions. The article relates worrying evidence of a disparity in the delivery of evidence-based treatment, raising many important questions: What barriers are preventing women from presenting for treatment earlier? Why are there delays in providing women with recognised life-saving treatments? Why are women as a group treated less intensively than men despite having higher Global Registry of Acute Coronary Events (GRACE) risk scores? What biological differences require distinct therapeutic approaches and dedicated clinical trials?


        • 1 St Vincent's Hospital Melbourne, Melbourne, VIC
        • 2 Kolling Institute of Medical Research, Sydney, NSW


        Correspondence: andrew.macisaac@svha.org.au
        Competing interests:

        No relevant disclosures.

        • 1. Khan E, Brieger D, Amerena J, et al. Differences in management and outcomes for men and women with ST-elevation myocardial infarction. Med J Aust 2018; 209: 118-123.
        • 2. Heart Foundation. 2018. Women and heart disease. 2018. https://www.heartfoundation.org.au/your-heart/women-and-heart-disease (viewed 21 June 2018).
        • 3. Wei J, Mehta PK, Grey E, et al. Sex-based differences in quality of care and outcomes in a health system using a standardized STEMI protocol. Am Heart J 2017; 191: 30-36.
        • 4. Chew DP, Scott IA, Cullen L, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. Med J Aust 2016; 205: 128-133. <MJA full text>
        • 5. Bavishi C, Bangalore S, Patel D, et al. Short and long-term mortality in women and men undergoing primary angioplasty: a comprehensive meta-analysis. Int J Cardiol 2015; 198: 123-130.
        • 6. Bugiardini R, Ricci B, Cenko E, et al. Delayed care and mortality among women and men with myocardial infarction. J Am Heart Assoc 2017; 6: doi: 10.1161/JAHA.117.005968.
        • 7. Zimmermann S, Ruthrof S, Nowak K, et al. Short-term prognosis of contemporary interventional therapy of ST-elevation myocardial infarction: does gender matter? Clin Res Cardiol 2009; 98: 709-715.
        • 8. Vaccarino V, Parsons L, Peterson ED, et al. Sex differences in mortality after acute myocardial infarction: changes from 1994 to 2006. Arch Intern Med 2009; 169: 1767-1774.
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          Potential implications of the new American hypertension guidelines in Australia

          Garry LR Jennings, Bronwyn A Kingwell and Erin Hoare
          Med J Aust 2018; 209 (3): . || doi: 10.5694/mja18.00104
          Published online: 6 August 2018

          There are significant population health and economic implications if Australia were to adopt recently revised American guidelines

          There are few things more controversial in medicine than when authoritative bodies shift the goalposts for common conditions and redefine normal values. This is particularly the case when the normative values for common chronic disease risk factors in the community, such as blood pressure or cholesterol, are made more stringent. In the stroke of a pen, millions of people have a disease or a risk factor they did not have the day before. Is this “the medicalisation of life” referred to by Illich?


          • 1 University of Sydney, Sydney, NSW
          • 2 Baker Heart and Diabetes Institute, Melbourne, VIC
          • 3 Food and Mood Centre, Deakin University, Geelong, VIC
          • 4 Centre for Innovation in Mental and Physical Health and Clinical Treatment, Deakin University, Geelong, VIC


          Acknowledgements: 

          This work was supported by funding from the Australian National Health and Medical Research Council (NHMRC) (Program Grant #1036352, and Centre for Research Excellence Grant #1000986) and the Victorian Government’s Operational Infrastructure Support Program (Garry Jennings and Bronwyn Kingwell). Erin Hoare was supported by an Australian Rotary Health Postdoctoral Research Fellowship. Bronwyn Kingwell was supported by an NHMRC Senior Principal Research Fellowship (NHMRC #1059454).

          Competing interests:

          Garry Jennings is Chief Medical Advisor of the Heart Foundation.

          • 1. Illich I. Medical nemesis: the expropriation of health. New York: Pantheon Books, 1976.
          • 2. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017; 13: 24430.
          • 3. Maddox TM, Borden WB, Tang F, et al. Implications of the 2013 ACC/AHA cholesterol guidelines for adults in contemporary cardiovascular practice: insights from the NCDR PINNACLE registry. J Am Coll Cardiol 2014; 64: 2183-2192.
          • 4. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. Guidelines for preventing and treating vitamin D deficiency and insufficiency revisited. J Clin Endocrinol Metab 2012; 97: 1153-1158.
          • 5. SPRINT Research Group. A randomized trial of intensive versus standard blood- pressure control. N Engl J Med 2015; 373: 2103-2116.
          • 6. Muntner P, Carey RM, Gidding S, et al. Potential US population impact of the 2017 ACC/AHA high blood pressure guideline. J Am Coll Cardiol 2018; 71: 109-118.
          • 7. Gabb GM, Mangoni AA, Anderson CS, et al. Guideline for the diagnosis and management of hypertension in adults — 2016. Med J Aust 2016; 205: 85-89. <MJA full text>
          • 8. Wang JG, Liu L. Global impact of 2017 American College of Cardiology/American Heart Association Hypertension guidelines: a perspective from China. Circulation 2018; 137: 546-548.
          • 9. Schiffrin EL. Global impact of the 2017 American College of Cardiology/American Heart Association Hypertension guidelines: a perspective from Canada. Circulation 2018; 137: 883-885.
          • 10. Wander GS, Ram CVS. Global impact of the 2017 American College of Cardiology/American Heart Association Hypertension guidelines: a perspective from India. Circulation 2018; 137: 549-550.
          • 11. Australian Bureau of Statistics. National Health Survey: first results, 2014–15 (Cat. No. 4364.0.55.001). Canberra: ABS, 2015. http://www.abs.gov.au/ausstats/abs@.nsf/mf/4364.0.55.001 (viewed May 2018).
          • 12. Hoare E, Kingwell BA, Jennings GLR. Blood pressure Down Under, but down under what? US and Australian hypertension guideline conversation. Hypertension 2018; 71: 972-975.
          • 13. Gee ME, Campbell N, Sarrafzadegan N, et al. Standards for the uniform reporting of hypertension in adults using population survey data: recommendations from the World Hypertension League Expert Committee. J Clin Hypertens (Greenwich) 2014; 16: 773-781.
          • 14. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey; 2013–2014 data documentation, codebook, and frequencies; blood pressure [website]. Atlanta, GA: CDC, 2015. https://wwwn.cdc.gov/Nchs/Nhanes/2013-2014/BPX_H.htm (viewed Mar 2018).
          • 15. National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk. Melbourne: National Stroke Foundation, 2012. https://www.heartfoundation.org.au/images/uploads/publications/Absolute-CVD-Risk-Full-Guidelines.pdf (viewed May 2018).
          • 16. Karakaya G, Van Tielen R, Umbach I. [OP.6C.02] Risk factors associated with medication non-compliance in arterial hypertension. J Hypertens 2016; 34: e72.
          • 17. American Academy of Family Physicians. Guidelines developed by external organizations not endorsed by the AAFP [website]. AAFP, 2017. https://www.aafp.org/patient-care/clinical-recommendations/non-endorsed.html (viewed Mar 2018).
          • 18. Hoare E, Stavreski B, Kingwell BA, Jennings GL. Australian adults’ behaviours, knowledge and perceptions of risk factors for heart disease: a cross-sectional study. Prev Med Rep 2017; 8: 204-209.
          • 19. Australian Institute of Health and Welfare. Australian burden of disease study: impact and causes of illness and death in Australia 2011. Canberra: AIHW, 2016. https://www.aihw.gov.au/getmedia/d4df9251-c4b6-452f-a877-8370b6124219/19663.pdf.aspx?inline=true (viewed May 2018).
          • 20. Rose G. Sick individuals and sick populations. Int J Epidemiol 2001; 30: 427-432.
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            Glycaemic control apps for diabetes: lifting the lid

            Rahul Barmanray and Esther Briganti
            Med J Aust 2018; 209 (10): . || doi: 10.5694/mja18.00066
            Published online: 30 July 2018

            The rapidly expanding diabetes app market presents new challenges for patients, health care providers and regulators

            The medical technology industry’s explosive growth has set the stage for medical mobile applications (apps) to assist with the management of many chronic diseases. Diabetes mellitus is the archetypal example: its management requires optimising diet, physical activity, blood glucose self-monitoring, and safe medication use. As a multifaceted condition affecting so many people, diabetes is the perfect target for developers of medical apps to realise the promise of the digital revolution.


            • 1 Royal Melbourne Hospital, Melbourne, VIC
            • 2 Monash University, Melbourne, VIC


            Correspondence: rahul.barmanray@mh.org.au
            Competing interests:

            No relevant disclosures.

            • 1. Wu Y, Yao X, Vespasiani G, et al. Mobile app-based interventions to support diabetes self-management: a systematic review of randomized controlled trials to identify functions associated with glycemic efficacy. JMIR Mhealth Uhealth 2017; 5: e35.
            • 2. Arnhold M, Quade M, Kirch W. Mobile applications for diabetics: a systematic review and expert-based usability evaluation considering the special requirements of diabetes patients age 50 years or older. J Med Internet Res 2014; 16: e104.
            • 3. Bonoto BC, de Araújo VE, Godói IP, et al. Efficacy of mobile apps to support the care of patients with diabetes mellitus: a systematic review and meta-analysis of randomized controlled trials. JMIR Mhealth Uhealth 2017; 5: e4.
            • 4. Chaudhury A, Duvoor C, Reddy Dendi VS, et al. Clinical review of antidiabetic drugs: implications for type 2 diabetes mellitus management. Front Endocrinol (Lausanne) 2017; 8: 6.
            • 5. Rossi MC, Nicolucci A, Lucisano G, et al; DID Study Group. Impact of the “Diabetes Interactive Diary” telemedicine system on metabolic control, risk of hypoglycemia, and quality of life: a randomized clinical trial in type 1 diabetes. Diabetes Technol Ther 2013; 15: 670-679.
            • 6. Charpentier G, Benhamou PY, Dardari D, et al; TeleDiab Study Group. The Diabeo software enabling individualized insulin dose adjustments combined with telemedicine support improves HbA1c in poorly controlled type 1 diabetic patients: a 6-month, randomized, open-label, parallel-group, multicenter trial (TeleDiab 1 Study). Diabetes Care 2011; 34: 533-539.
            • 7. Huckvale K, Adomaviciute S, Prieto JT, et al. Smartphone apps for calculating insulin dose: a systematic assessment. BMC Med 2015; 13: 106.
            • 8. Therapeutic Goods Administration. Australian regulatory guidelines for medical devices (ARGMD), section 5. Conformity assessment overview V1.1 May 2011. https://www.tga.gov.au/sites/default/files/devices-argmd-p1-01.pdf (viewed July 2018).
            • 9. Sansom L, Delaat W, Horvath J. Review of medicines and medical devices regulation: report on the regulatory framework for medicines and medical devices. (Sansom Review; Stage One) March 2015. Commonwealth of Australia; 2015.
            • 10. European Commission. Regulatory Framework. Regulation (EU) 2017/745 of the European Parliament and of the Council of 5 April 2017 on medical devices, amending Directive 2001/83/EC, Regulation (EC) No 178/2002 and Regulation (EC) No 1223/2009 and repealing Council Directives 90/385/EEC and 93/42/EEC. https://ec.europa.eu/growth/sectors/medical-devices/regulatory-framework_en (viewed Jan 2018).
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              Thyroid nodules: diagnosis and management

              Rosemary Wong, Stephen G Farrell and Mathis Grossmann
              Med J Aust 2018; 209 (2): . || doi: 10.5694/mja17.01204
              Published online: 16 July 2018

              Summary

               

              • Thyroid nodules are common. Their importance lies in the need to assess thyroid function, degree of and future risk of mass effect, and exclude thyroid cancer, which occurs in 7–15% of thyroid nodules.
              • There are four key components to thyroid nodule assessment: clinical history and examination, serum thyroid stimulating hormone (TSH) measurement, ultrasound and, if indicated, fine-needle aspiration (FNA).
              • If the serum TSH is suppressed, a thyroid scan with 99Tc can distinguish between a solitary hot nodule, a toxic multinodular goitre or, less commonly, thyroiditis or Graves’ disease within a coexisting nodular thyroid. Scintigraphically cold nodules are evaluated in the same way as in the setting of normal or elevated serum TSH levels.
              • Thyroid ultrasonography should be performed only for palpable goitre and thyroid nodules and by specialists with expertise in thyroid sonography.
              • Routine thyroid cancer screening is not recommended, except in high risk individuals, as the detection of early thyroid cancer has not been shown to improve survival.
              • FNA may be performed for nodules ≥ 1.0 cm depending on clinical and sonographic risk factors for thyroid cancer.
              • FNA specimens should be read by an experienced cytopathologist and be reported according to the Bethesda Classification System.
              • Molecular analysis of indeterminate FNA samples has potential to better discriminate benign from malignant nodules and thus guide management.
              • Surgery is indicated for FNA findings of malignancy or indeterminate cytology when there is a high risk clinical context. Surgery may also be indicated for suspicion of malignancy; larger nodules, especially with symptoms of mass effect; and in some patients with thyrotoxicosis.

               


              • 1 Eastern Health, Melbourne, VIC
              • 2 Austin Health, Melbourne, VIC
              • 3 St Vincent's Hospital, Melbourne, VIC
              • 4 University of Melbourne, Melbourne, VIC


              Correspondence: mathisg@unimelb.edu.au
              Competing interests:

              No relevant disclosures.

              • 1. Burman KD, Wartofsky L. Clinical practice. Thyroid nodules. N Engl J Med 2015; 373: 2347-2356.
              • 2. Walsh JP. Managing thyroid disease in general practice. Med J Aust 2016; 205: 179-184. <MJA full text>
              • 3. Soelberg KK, Bonnema SJ, Brix TH, Hegedüs L. Risk of malignancy in thyroid incidentalomas detected by 18F-fluorodeoxyglucose positron emission tomography: a systematic review. Thyroid 2012; 22: 918-925.
              • 4. Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association Guidelines Task Force on thyroid nodules and differentiated thyroid cancer. Thyroid 2016; 26: 1-133.
              • 5. Cancer Australia. Thyroid cancer statistics. Commonwealth of Australia; 2014. https://thyroid-cancer.canceraustralia.gov.au/statistics (viewed Nov 2017).
              • 6. Grani G, Lamartina L, Durante C, et al. Follicular thyroid cancer and Hürthle cell carcinoma: challenges in diagnosis, treatment, and clinical management. Lancet Diabetes Endocrinol 2018; 6: 500-514.
              • 7. Mazzaferri EL. Management of a solitary thyroid nodule. N Engl J Med 1993; 328: 553-559.
              • 8. Angell TE, Vyas C, Medici M, et al. Differential growth rates of benign versus malignant thyroid nodules. J Clin Endocrinol Metab 2017; 102: 4642-4647.
              • 9. Durante C, Costante G, Lucisano G, et al. The natural history of benign thyroid nodules. JAMA 2015; 313: 926-935.
              • 10. Sosa JA, Duh QY, Doherty G. Striving for clarity about the best approach to thyroid cancer screening and treatment: is the pendulum swinging too far? JAMA Surg 2017; 152: 721-722.
              • 11. US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for thyroid cancer: US Preventive Services Task Force recommendation statement. JAMA 2017; 317: 1882-1887.
              • 12. Chen AY, Jemal A, Ward EM. Increasing incidence of differentiated thyroid cancer in the United States, 1988–2005. Cancer 2009; 115: 3801-3807.
              • 13. Pandeya N, McLeod DS, Balasubramaniam K, et al. Increasing thyroid cancer incidence in Queensland, Australia 1982–2008 — true increase or overdiagnosis? Clin Endocrinol (Oxf) 2016; 84: 257-264.
              • 14. Lim H, Devesa SS, Sosa JA, et al. Trends in thyroid cancer incidence and mortality in the United States, 1974–2013. JAMA 2017; 317: 1338-1348.
              • 15. Kitahara CM, Sosa JA. The changing incidence of thyroid cancer. Nat Rev Endocrinol 2016; 12: 646-653.
              • 16. Schneider AB, Ron E, Lubin J, et al. Dose-response relationships for radiation-induced thyroid cancer and thyroid nodules: evidence for the prolonged effects of radiation on the thyroid. J Clin Endocrinol Metab 1993; 77: 362-369.
              • 17. Curtis RE, Rowlings PA, Deeg HJ, et al. Solid cancers after bone marrow transplantation. N Engl J Med 1997; 336: 897-904.
              • 18. Shibata Y, Yamashita S, Masyakin VB, et al. 15 years after Chernobyl: new evidence of thyroid cancer. Lancet 2001; 358: 1965-1966.
              • 19. Samuels MH. Subacute, silent, and postpartum thyroiditis. Med Clin North Am 2012; 96: 223-233.
              • 20. Knobel M. Etiopathology, clinical features, and treatment of diffuse and multinodular nontoxic goiters. J Endocrinol Invest 2016; 39: 357-373.
              • 21. Boelaert K, Horacek J, Holder RL, et al. Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules investigated by fine-needle aspiration. J Clin Endocrinol Metab 2006; 91: 4295-4301.
              • 22. Haymart MR, Repplinger DJ, Leverson GE, et al. Higher serum thyroid stimulating hormone level in thyroid nodule patients is associated with greater risks of differentiated thyroid cancer and advanced tumor stage. J Clin Endocrinol Metab 2008; 93: 809-814.
              • 23. Wells SA, Asa SL, Dralle H, et al. Revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma. Thyroid 2015; 25: 567-610.
              • 24. Hoang JK, Lee WK, Lee M, et al. US Features of thyroid malignancy: pearls and pitfalls. Radiographics 2007; 27: 847-860; discussion 861-865.
              • 25. Brito JP, Gionfriddo MR, Al Nofal A, et al. The accuracy of thyroid nodule ultrasound to predict thyroid cancer: systematic review and meta-analysis. J Clin Endocrinol Metab 2014; 99: 1253-1263.
              • 26. Remonti LR, Kramer CK, Leitão CB, et al. Thyroid ultrasound features and risk of carcinoma: a systematic review and meta-analysis of observational studies. Thyroid 2015; 25: 538-550.
              • 27. Bonavita JA, Mayo J, Babb J, et al. Pattern recognition of benign nodules at ultrasound of the thyroid: which nodules can be left alone? AJR Am J Roentgenol 2009; 193: 207-213.
              • 28. Tessler FN, Middleton WD, Grant EG, et al. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): white paper of the ACR TI-RADS Committee. J Am Coll Radiol 2017; 14: 587-595.
              • 29. Tsirona S, Vlassopoulou V, Tzanela M, et al. Impact of early vs late postoperative radioiodine remnant ablation on final outcome in patients with low-risk well-differentiated thyroid cancer. Clin Endocrinol (Oxf) 2014; 80: 459-463.
              • 30. Suman P, Wang CH, Abadin SS, et al. Timing of radioactive iodine therapy does not impact overall survival in high-risk papillary thyroid carcinoma. Endocr Pract 2016; 22: 822-831.
              • 31. Topliss D. Thyroid incidentaloma: the ignorant in pursuit of the impalpable. Clin Endocrinol (Oxf) 2004; 60: 18-20.
              • 32. Yap NS, Maher R, Learoyd DL. Any detectable thyroglobulin in lymph node biopsy washouts suggests local recurrence in differentiated thyroid cancer. Endocr Connect 2014; 3: 150-155.
              • 33. Cibas ES, Ali SZ, National Cancer Institute Thyroid FNA State of the Science Conference. The Bethesda System for reporting thyroid cytopathology. Am J Clin Pathol 2009; 132: 658-665.
              • 34. Tamhane S, Gharib H. Thyroid nodule update on diagnosis and management. Clin Diabetes Endocrinol 2016; 2: 17.
              • 35. Baloch ZW, Cibas ES, Clark DP, et al. The National Cancer Institute thyroid fine needle aspiration state of the science conference: a summation. CytoJournal 2008; 5: 6.
              • 36. Oertel YC, Miyahara-Felipe L, Mendoza MG, Yu K. Value of repeated fine needle aspirations of the thyroid: an analysis of over ten thousand FNAs. Thyroid 2007; 17: 1061-1066.
              • 37. Bongiovanni M, Spitale A, Faquin WC, et al. The Bethesda System for reporting thyroid cytopathology: a meta-analysis. Acta Cytol 2012; 56: 333-339.
              • 38. Giles WH, Maclellan RA, Gawande AA, et al. False negative cytology in large thyroid nodules. Ann Surg Oncol 2015; 22: 152-157.
              • 39. Mond M, Alexiadis M, Eriksson N, et al. Nuclear receptor expression in human differentiated thyroid tumors. Thyroid 2014; 24: 1000-1011.
              • 40. Zhang M, Lin O. Molecular testing of thyroid nodules: a review of current available tests for fine-needle aspiration specimens. Arch Pathol Lab Med 2016; 140: 1338-1344.
              • 41. Alexander EK, Kennedy GC, Baloch ZW, et al. Preoperative diagnosis of benign thyroid nodules with indeterminate cytology. N Engl J Med 2012; 367: 705-715.
              • 42. Labourier E, Shifrin A, Busseniers AE, et al. Molecular testing for miRNA, mRNA, and DNA on fine-needle aspiration improves the preoperative diagnosis of thyroid nodules with indeterminate cytology. J Clin Endocrinol Metab 2015; 100: 2743-2750.
              • 43. Nikiforova MN, Wald AI, Roy S, et al. Targeted next-generation sequencing panel (ThyroSeq) for detection of mutations in thyroid cancer. J Clin Endocrinol Metab 2013; 98: E1852-E1860.
              • 44. Nikiforov YE, Carty SE, Chiosea SI, et al. Highly accurate diagnosis of cancer in thyroid nodules with follicular neoplasm/suspicious for a follicular neoplasm cytology by ThyroSeq v2 next-generation sequencing assay. Cancer 2014; 120: 3627-3634.
              • 45. Ito Y, Miyauchi A, Oda H. Low-risk papillary microcarcinoma of the thyroid: a review of active surveillance trials. Eur J Surg Oncol 2018; 44: 307-315.
              • 46. Kamran SC, Marqusee E, Kim MI, et al. Thyroid nodule size and prediction of cancer. J Clin Endocrinol Metab 2013; 98: 564-570.
              • 47. Wharry LI, McCoy KL, Stang MT, et al. Thyroid nodules (≥ 4 cm): can ultrasound and cytology reliably exclude cancer? World J Surg 2014; 38: 614-621.
              • 48. Kwak JY, Koo H, Youk JH, et al. Value of US correlation of a thyroid nodule with initially benign cytologic results. Radiology 2010; 254: 292-300.
              • 49. Herzon FS, Morris DM, Segal MN, et al. Coexistent thyroid cancer and pregnancy. Arch Otolaryngol Head Neck Surg 1994; 120: 1191-1193.
              • 50. Moosa M, Mazzaferri EL. Outcome of differentiated thyroid cancer diagnosed in pregnant women. J Clin Endocrinol Metab 1997; 82: 2862-2866.
              • 51. Gharib H, Papini E, Garber JR, et al. American Association of Clinical Endocrinologists, American College of Endocrinology, and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules — 2016 update. Endocr Pract 2016; 22: 622-639.
              • 52. American Thyroid Association Taskforce on Radioiodine Safety; Sisson JC, Freitas J, McDougall IR, et al. Radiation safety in the treatment of patients with thyroid diseases by radioiodine 131I: practice recommendations of the American Thyroid Association. Thyroid 2011; 21: 335-346.
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                Chronic idiopathic constipation in adults: epidemiology, pathophysiology, diagnosis and clinical management

                Christopher J Black and Alexander C Ford
                Med J Aust 2018; 209 (2): . || doi: 10.5694/mja18.00241
                Published online: 16 July 2018

                Summary

                 

                • Chronic idiopathic constipation (CIC) is one of the most common gastrointestinal disorders, with a global prevalence of 14%. It is commoner in women and its prevalence increases with age.
                • There are three subtypes of CIC: dyssynergic defaecation, slow transit constipation and normal transit constipation, which is the most common subtype.
                • Clinical assessment of the patient with constipation requires careful history taking, in order to identify any red flag symptoms that would necessitate further investigation with colonoscopy to exclude colorectal malignancy.
                • Screening for hypercalcaemia, hypothyroidism and coeliac disease with appropriate blood tests should be considered.
                • A digital rectal examination should be performed to assess for evidence of dyssynergic defaecation. If this is suspected, further investigation with high resolution anorectal manometry should be undertaken.
                • Anorectal biofeedback can be offered to patients with dyssynergic defaecation as a means of correcting the associated impairment of pelvic floor, abdominal wall and rectal functioning.
                • Lifestyle modifications, such as increasing dietary fibre, are the first step in managing other causes of CIC. If patients do not respond to these simple changes, then treatment with osmotic and stimulant laxatives should be trialled.
                • Patients not responding to traditional laxatives should be offered treatment with prosecretory agents such as lubiprostone, linaclotide and plecanatide, or the 5-HT4 receptor agonist prucalopride, where available.
                • If there is no response to pharmacological treatment, surgical intervention can be considered, but it is only suitable for a carefully selected subset of patients with proven slow transit constipation.

                 


                • Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK


                Correspondence: A.C.Ford@leeds.ac.uk
                Competing interests:

                No relevant disclosures.

                • 1. Peery AF, Crockett SD, Barritt AS, et al. Burden of gastrointestinal, liver, and pancreatic diseases in the United States. Gastroenterology 2015; 149: 1731-1741.e3.
                • 2. Shahid S, Ramzan Z, Maurer AH, et al. Chronic idiopathic constipation: more than a simple colonic transit disorder. J Clin Gastroenterol 2012; 46: 150-154.
                • 3. Mearin F, Lacy BE, Chang L, et al. Bowel disorders. Gastroenterology 2016; 150: 1393-1407.
                • 4. Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol 1997; 32: 920-924.
                • 5. Degen LP, Phillips SF. How well does stool form reflect colonic transit? Gut 1996; 39: 109-113.
                • 6. Saad RJ, Rao SS, Koch KL, et al. Do stool form and frequency correlate with whole-gut and colonic transit? Results from a multicenter study in constipated individuals and healthy controls. Am J Gastroenterol 2010; 105: 403-411.
                • 7. Chaussade S, Khyari A, Roche H, et al. Determination of total and segmental colonic transit time in constipated patients. Results in 91 patients with a new simplified method. Dig Dis Sci 1989; 34: 1168-1172.
                • 8. Tornblom H, Van Oudenhove L, Sadik R, et al. Colonic transit time and IBS symptoms: what’s the link? Am J Gastroenterol 2012; 107: 754-760.
                • 9. Whitehead WE, Palsson OS, Simren M. Biomarkers to distinguish functional constipation from irritable bowel syndrome with constipation. Neurogastroenterol Motil 2016; 28: 783-792.
                • 10. Wong RK, Palsson OS, Turner MJ, et al. Inability of the Rome III criteria to distinguish functional constipation from constipation-subtype irritable bowel syndrome. Am J Gastroenterol 2010; 105: 2228-2234.
                • 11. Suares NC, Ford AC. Prevalence of, and risk factors for, chronic idiopathic constipation in the community: Systematic review and meta-analysis. Am J Gastroenterol 2011; 106: 1582-1591; quiz 1, 92.
                • 12. Vazquez Roque M, Bouras EP. Epidemiology and management of chronic constipation in elderly patients. Clin Interv Aging 2015; 10: 919-930.
                • 13. Ford AC, Bercik P, Morgan DG, et al. Characteristics of functional bowel disorder patients: a cross-sectional survey using the Rome III criteria. Aliment Pharmacol Ther 2014; 39: 312-321.
                • 14. Bytzer P, Howell S, Leemon M, et al. Low socioeconomic class is a risk factor for upper and lower gastrointestinal symptoms: a population based study in 15 000 Australian adults. Gut 2001; 49: 66-72.
                • 15. Holdstock DJ, Misiewicz JJ, Smith T, Rowlands EN. Propulsion (mass movements) in the human colon and its relationship to meals and somatic activity. Gut 1970; 11: 91-99.
                • 16. Smith TK, Park KJ, Hennig GW. Colonic migrating motor complexes, high amplitude propagating contractions, neural reflexes and the importance of neuronal and mucosal serotonin. J Neurogastroenterol Motil 2014; 20: 423-446.
                • 17. Spencer NJ. Constitutively active 5-HT receptors: an explanation of how 5-HT antagonists inhibit gut motility in species where 5-HT is not an enteric neurotransmitter? Front Cell Neurosci 2015; 9: 487.
                • 18. Radenkovic G, Radenkovic D, Velickov A. Development of interstitial cells of Cajal in the human digestive tract as the result of reciprocal induction of mesenchymal and neural crest cells. J Cell Mol Med 2018; 22: 778-785.
                • 19. Lin AY, Du P, Dinning PG, et al. High-resolution anatomic correlation of cyclic motor patterns in the human colon: evidence of a rectosigmoid brake. Am J Physiol Gastrointest Liver Physiol 2017; 312: G508-G515.
                • 20. Sandle GI. Salt and water absorption in the human colon: a modern appraisal. Gut 1998; 43: 294-299.
                • 21. Thomas RH, Luthin DR. Current and emerging treatments for irritable bowel syndrome with constipation and chronic idiopathic constipation: focus on prosecretory agents. Pharmacotherapy 2015; 35: 613-630.
                • 22. Krogh K, Chiarioni G, Whitehead W. Management of chronic constipation in adults. United European Gastroenterol J 2017; 5: 465-472.
                • 23. Camilleri M, Ford AC, Mawe GM, et al. Chronic constipation. Nat Rev Dis Primers 2017; 3: 17095.
                • 24. Abrahamsson H, Ostlund-Lindqvist AM, Nilsson R, et al. Altered bile acid metabolism in patients with constipation-predominant irritable bowel syndrome and functional constipation. Scand J Gastroenterol 2008; 43: 1483-1488.
                • 25. Triantafyllou K, Chang C, Pimentel M. Methanogens, methane and gastrointestinal motility. J Neurogastroenterol Motil 2014; 20: 31-40.
                • 26. Parthasarathy G, Chen J, Chen X, et al. Relationship between microbiota of the colonic mucosa vs feces and symptoms, colonic transit, and methane production in female patients with chronic constipation. Gastroenterology 2016; 150: 367-379.e1.
                • 27. Markland AD, Palsson O, Goode PS, et al. Association of low dietary intake of fiber and liquids with constipation: evidence from the National Health and Nutrition Examination Survey. Am J Gastroenterol 2013; 108: 796-803.
                • 28. Mazlyn MM, Nagarajah LH, Fatimah A, et al. Stool patterns of Malaysian adults with functional constipation: association with diet and physical activity. Malays J Nutr 2013; 19: 53-64.
                • 29. Chan AO, Cheng C, Hui WM, et al. Differing coping mechanisms, stress level and anorectal physiology in patients with functional constipation. World J Gastroenterol 2005; 11: 5362-5366.
                • 30. Rao SS, Welcher KD, Leistikow JS. Obstructive defecation: a failure of rectoanal coordination. Am J Gastroenterol 1998; 93: 1042-1050.
                • 31. Nullens S, Nelsen T, Camilleri M, et al. Regional colon transit in patients with dys-synergic defaecation or slow transit in patients with constipation. Gut 2012; 61: 1132-1139.
                • 32. Rao SS, Tuteja AK, Vellema T, et al. Dyssynergic defecation: demographics, symptoms, stool patterns, and quality of life. J Clin Gastroenterol 2004; 38: 680-685.
                • 33. Perniola G, Shek C, Chong CC, et al. Defecation proctography and translabial ultrasound in the investigation of defecatory disorders. Ultrasound Obstet Gynecol 2008; 31: 567-571.
                • 34. Bassotti G, Iantorno G, Fiorella S, et al. Colonic motility in man: features in normal subjects and in patients with chronic idiopathic constipation. Am J Gastroenterol 1999; 94: 1760-1770.
                • 35. Dinning PG, Wiklendt L, Maslen L, et al. Colonic motor abnormalities in slow transit constipation defined by high resolution, fibre-optic manometry. Neurogastroenterol Motil 2015; 27: 379-388.
                • 36. Bassotti G, Gaburri M, Imbimbo BP, et al. Colonic mass movements in idiopathic chronic constipation. Gut 1988; 29: 1173-1179.
                • 37. Dinning PG, Zarate N, Hunt LM, et al. Pancolonic spatiotemporal mapping reveals regional deficiencies in, and disorganization of colonic propagating pressure waves in severe constipation. Neurogastroenterol Motil 2010; 22: e340-e349.
                • 38. Bassotti G, Chiarioni G, Vantini I, et al. Anorectal manometric abnormalities and colonic propulsive impairment in patients with severe chronic idiopathic constipation. Dig Dis Sci 1994; 39: 1558-1564.
                • 39. Lyford GL, He CL, Soffer E, et al. Pan-colonic decrease in interstitial cells of Cajal in patients with slow transit constipation. Gut 2002; 51: 496-501.
                • 40. Tong WD, Liu BH, Zhang LY, et al. Decreased interstitial cells of Cajal in the sigmoid colon of patients with slow transit constipation. Int J Colorectal Dis 2004; 19: 467-473.
                • 41. Power AM, Talley NJ, Ford AC. Association between constipation and colorectal cancer: Systematic review and meta-analysis of observational studies. Am J Gastroenterol 2013; 108: 894-903; quiz 4.
                • 42. Spijkerman M, Tan IL, Kolkman JJ, et al. A large variety of clinical features and concomitant disorders in celiac disease - A cohort study in the Netherlands. Dig Liver Dis 2016; 48: 499-505.
                • 43. Park SK, Myung SJ, Jung KW, et al. Biofeedback therapy for female patients with constipation caused by radical hysterectomy or vaginal delivery. J Gastroenterol Hepatol 2013; 28: 1133-1140.
                • 44. Varma MG, Hart SL, Brown JS, et al. Obstructive defecation in middle-aged women. Dig Dis Sci 2008; 53: 2702-2709.
                • 45. Kepenekci I, Keskinkilic B, Akinsu F, et al. Prevalence of pelvic floor disorders in the female population and the impact of age, mode of delivery, and parity. Dis Colon Rectum 2011; 54: 85-94.
                • 46. Talley NJ. How to do and interpret a rectal examination in gastroenterology. Am J Gastroenterol 2008; 103: 820-822.
                • 47. Soh JS, Lee HJ, Jung KW, et al. The diagnostic value of a digital rectal examination compared with high-resolution anorectal manometry in patients with chronic constipation and fecal incontinence. Am J Gastroenterol 2015; 110: 1197-1204.
                • 48. Tantiphlachiva K, Rao P, Attaluri A, Rao SSC. Digital rectal examination is a useful tool for identifying patients with dyssynergia. Clin Gastroenterol Hepatol 2010; 8: 955-960.
                • 49. Basilisco G, Bharucha AE. High-resolution anorectal manometry: an expensive hobby or worth every penny? Neurogastroenterol Motil 2017; 29: doi: 10.1111/nmo.13125.
                • 50. Hinton JM, Lennard-Jones JE, Young AC. A new method for studying gut transit times using radioopaque markers. Gut 1969; 10: 842-847.
                • 51. Staller K, Barshop K, Ananthakrishnan AN, Kuo B. Number of retained radiopaque markers on a colonic transit study does not correlate with symptom severity or quality of life in chronic constipation. Neurogastroenterol Motil 2018; 30: e13269.
                • 52. Ziessman HA. Gastrointestinal transit assessment: role of scintigraphy: Where are we now? Where are we going? Curr Treat Options Gastroenterol 2016; 14: 452-460.
                • 53. Diaz Tartera HO, Webb DL, Al-Saffar AK, et al. Validation of SmartPill((R)) wireless motility capsule for gastrointestinal transit time: intra-subject variability, software accuracy and comparison with video capsule endoscopy. Neurogastroenterol Motil 2017; 29: 1-9.
                • 54. Payler DK, Pomare EW, Heaton KW, Harvey RF. The effect of wheat bran on intestinal transit. Gut 1975; 16: 209-213.
                • 55. Marteau P, Flourie B, Cherbut C, et al. Digestibility and bulking effect of ispaghula husks in healthy humans. Gut 1994; 35: 1747-1752.
                • 56. Suares NC, Ford AC. Systematic review: the effects of fibre in the management of chronic idiopathic constipation. Aliment Pharmacol Ther 2011; 33: 895-901.
                • 57. Christodoulides S, Dimidi E, Fragkos KC, et al. Systematic review with meta-analysis: effect of fibre supplementation on chronic idiopathic constipation in adults. Aliment Pharmacol Ther 2016; 44: 103-116.
                • 58. Dimidi E, Christodoulides S, Fragkos KC, et al. The effect of probiotics on functional constipation in adults: a systematic review and meta-analysis of randomized controlled trials. Am J Clin Nutr 2014; 100: 1075-1084.
                • 59. Ford AC, Quigley EM, Lacy BE, et al. Efficacy of prebiotics, probiotics, and synbiotics in irritable bowel syndrome and chronic idiopathic constipation: systematic review and meta-analysis. Am J Gastroenterol 2014; 109: 1547-1561; quiz 6, 62.
                • 60. Müller-Lissner SA, Kamm MA, Scarpignato C, Wald A. Myths and misconceptions about chronic constipation. Am J Gastroenterol 2005; 100: 232.
                • 61. Anti M, Pignataro G, Armuzzi A, et al. Water supplementation enhances the effect of high-fiber diet on stool frequency and laxative consumption in adult patients with functional constipation. Hepatogastroenterology 1998; 45: 727-732.
                • 62. Ziegenhagen DJ, Tewinkel G, Kruis W, Herrmann F. Adding more fluid to wheat bran has no significant effects on intestinal functions of healthy subjects. J Clin Gastroenterol 1991; 13: 525-530.
                • 63. Johannesson E, Simren M, Strid H, et al. Physical activity improves symptoms in irritable bowel syndrome: a randomized controlled trial. Am J Gastroenterol 2011; 106: 915-922.
                • 64. Hajizadeh Maleki B, Tartibian B, Mooren FC, et al. Low-to-moderate intensity aerobic exercise training modulates irritable bowel syndrome through antioxidative and inflammatory mechanisms in women: results of a randomized controlled trial. Cytokine 2017; 102: 18-25.
                • 65. Ford AC, Suares NC. Effect of laxatives and pharmacological therapies in chronic idiopathic constipation: Systematic review and meta-analysis. Gut 2011; 60: 209-218.
                • 66. Lee-Robichaud H, Thomas K, Morgan J, Nelson RL. Lactulose versus polyethylene glycol for chronic constipation. Cochrane Database Syst Rev 2010; (7): CD007570.
                • 67. Cinca R, Chera D, Gruss HJ, Halphen M. Randomised clinical trial: macrogol/PEG 3350+electrolytes versus prucalopride in the treatment of chronic constipation – a comparison in a controlled environment. Aliment Pharmacol Ther 2013; 37: 876-886.
                • 68. Kamm MA, Mueller-Lissner S, Wald A, et al. Oral bisacodyl is effective and well-tolerated in patients with chronic constipation. Clin Gastroenterol Hepatol 2011; 9: 577-583.
                • 69. Mueller-Lissner S, Kamm MA, Wald A, et al. Multicenter, 4-week, double-blind, randomized, placebo-controlled trial of sodium picosulfate in patients with chronic constipation. Am J Gastroenterol 2010; 105: 897-903.
                • 70. Nelson AD, Camilleri M, Chirapongsathorn S, et al. Comparison of efficacy of pharmacological treatments for chronic idiopathic constipation: a systematic review and network meta-analysis. Gut 2017; 66: 1611-1622.
                • 71. Mueller-Lissner SA, Wald A. Constipation in adults. BMJ Clin Evid 2010; 0413.
                • 72. Wald A. Is chronic use of stimulant laxatives harmful to the colon? J Clin Gastroenterol 2003; 36: 386-389.
                • 73. Li F, Fu T, Tong WD, et al. Lubiprostone is effective in the treatment of chronic idiopathic constipation and irritable bowel syndrome: a systematic review and meta-analysis of randomized controlled trials. Mayo Clin Proc 2016; 91: 456-468.
                • 74. Cryer B, Drossman DA, Chey WD, et al. Analysis of nausea in clinical studies of lubiprostone for the treatment of constipation disorders. Dig Dis Sci 2017; 62: 3568-3578.
                • 75. Lembo AJ, Schneier HA, Shiff SJ, et al. Two randomized trials of linaclotide for chronic constipation. N Engl J Med 2011; 365: 527-536.
                • 76. DeMicco M, Barrow L, Hickey B, et al. Randomized clinical trial: efficacy and safety of plecanatide in the treatment of chronic idiopathic constipation. Therap Adv Gastroenterol 2017; 10: 837-851.
                • 77. Miner PB Jr, Koltun WD, Wiener GJ, et al. A randomized phase III clinical trial of plecanatide, a uroguanylin analog, in patients with chronic idiopathic constipation. Am J Gastroenterol 2017; 112: 613-621.
                • 78. Camilleri M, Piessevaux H, Yiannakou Y, et al. Efficacy and safety of prucalopride in chronic constipation: an integrated analysis of six randomized, controlled clinical trials. Dig Dis Sci 2016; 61: 2357-2372.
                • 79. Goldberg M, Li YP, Johanson JF, et al. Clinical trial: the efficacy and tolerability of velusetrag, a selective 5-HT4 agonist with high intrinsic activity, in chronic idiopathic constipation - a 4-week, randomized, double-blind, placebo-controlled, dose-response study. Aliment Pharmacol Ther 2010; 32: 1102-1112.
                • 80. Camilleri M, Vazquez-Roque MI, Burton D, et al. Pharmacodynamic effects of a novel prokinetic 5-HT receptor agonist, ATI-7505, in humans. Neurogastroenterol Motil 2007; 19: 30-38.
                • 81. Acosta A, Camilleri M. Elobixibat and its potential role in chronic idiopathic constipation. Therap Adv Gastroenterol 2014; 7: 167-175.
                • 82. Bleijenberg G, Kuijpers HC. Biofeedback treatment of constipation: a comparison of two methods. Am J Gastroenterol 1994; 89: 1021-1026.
                • 83. Rao SS, Seaton K, Miller M, et al. Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation. Clin Gastroenterol Hepatol 2007; 5: 331-338.
                • 84. Woodward S, Norton C, Chiarelli P. Biofeedback for treatment of chronic idiopathic constipation in adults. Cochrane Database Syst Rev 2014; (3): CD008486.
                • 85. Coggrave M, Norton C. Management of faecal incontinence and constipation in adults with central neurological diseases. Cochrane Database Syst Rev 2013; (12): CD002115.
                • 86. Christensen P, Krogh K. Transanal irrigation for disordered defecation: a systematic review. Scand J Gastroenterol 2010; 45: 517-527.
                • 87. Juul T, Christensen P. Prospective evaluation of transanal irrigation for fecal incontinence and constipation. Tech Coloproctol 2017; 21: 363-371.
                • 88. Knowles CH, Grossi U, Horrocks EJ, et al. Surgery for constipation: Systematic review and practice recommendations. Colorectal Dis 2017; 19: 101-113.
                • 89. Hassan I, Pemberton JH, Young-Fadok TM, et al. Ileorectal anastomosis for slow transit constipation: Long-term functional and quality of life results. J Gastrointest Surg 2006; 10: 1330-1336.
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                  Severe asthma: implementing game-changing science

                  Peter G Gibson
                  Med J Aust 2018; 209 (2): . || doi: 10.5694/mja18.00477
                  Published online: 16 July 2018

                  New assessment and treatment opportunities for people with severe asthma promise better outcomes

                  “It’s been a long time coming, but I feel great now.” “I feel like I’ve got my life back.” These are statements made by patients with severe asthma who have had positive responses to targeted monoclonal antibody therapy for asthma. Both patients have severe refractory eosinophilic asthma and have experienced many years of persistent symptoms despite daily maintenance prednisone. On monoclonal antibody therapy, they achieved complete symptom control and significant prednisone reduction.


                  • John Hunter Hospital, Newcastle, NSW


                  Competing interests:

                  I have received honoraria for the delivery of independent medical education and grants from GlaxoSmithKline, AstraZeneca and Novartis. I am also a member of the MJA Editorial Advisory Group.

                  • 1. Upham JW, Chung LP. Optimising treatment for severe asthma. Med J Aust 2018; 209 (2 Suppl): S22-S27.
                  • 2. Lindstrom SJ, Silver JD, Sutherland MF, et al. Thunderstorm asthma outbreak of November 2016: a natural disaster requiring planning. Med J Aust 2017; 207: 235-237. <MJA full text>
                  • 3. McDonald VM, Hiles SA, Jones KA, et al. Health-related quality of life burden in severe asthma. Med J Aust 2018; 209 (2 Suppl): S28-S33.
                  • 4. Israel E, Reddel HK. Severe and difficult-to-treat asthma in adults. N Engl J Med 2017; 377: 965-976.
                  • 5. Tay TR, Lee JW-Y, Hew M. Diagnosis of severe asthma. Med J Aust 2018; 209 (2 Suppl): S3-S10.
                  • 6. Chung LP, Johnson P, Summers Q. Models of care for severe asthma: the role of primary care. Med J Aust 2018; 209 (2 Suppl): S34-S40.
                  • 7. Bardin PG, Rangaswamy J, Yo SW. Managing comorbid conditions in severe asthma. Med J Aust 2018; 209 (2 Suppl): S11-S17.
                  • 8. Ramsahai JM, Wark P. Appropriate use of oral steroids in severe asthma. Med J Aust 2018; 209 (2 Suppl): S18-S21.
                  • 9. Department of Health. An outcomes strategy for people with chronic obstructive pulmonary disease (COPD) and asthma in England. London: Department of Health, 2011. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_127974 (accessed May 2018).
                  • 10. von Bulow A, Kriegbaum M, Backer V, Porsbjerg C. The prevalence of severe asthma and low asthma control among Danish adults. J Allergy Clin Immunol Pract 2014; 2: 759-767.
                  • 11. Hekking PP, Wener RR, Amelink M, et al. The prevalence of severe refractory asthma. J Allergy Clin Immunol 2015; 135: 896-902.
                  • 12. Kane B, Cramb S, Hudson V, et al. Specialised commissioning for severe asthma: oxymoron or opportunity? Thorax 2016; 71: 196-198.
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                    The true price of sugar-sweetened disease: political inertia requires renewed, strategic action

                    Alessandro Demaio and Alexandra Jones
                    Med J Aust 2018; 209 (2): . || doi: 10.5694/mja18.00223
                    Published online: 9 July 2018

                    Australia can no longer afford to wait for a tax on sugar-sweetened beverages

                    Excess free sugars are a major contributor to diet-related diseases, including obesity, type 2 diabetes and tooth decay. Sugar-sweetened beverages (SSBs) provide a significant source of free sugars while offering no other nutritional benefit, making them a reasonable target for public health action., Governments worldwide are drawing on growing evidence to implement effective pricing policies for SSBs as one cornerstone of a comprehensive policy response.


                    • 1 University of Melbourne, Melbourne, VIC
                    • 2 EAT Foundation, Oslo, Norway
                    • 3 George Institute for Global Health, Sydney, NSW
                    • 4 Charles Perkins Centre, University of Sydney, Sydney, NSW


                    Acknowledgements: 

                    We thank Thomas Goodwin for his support in the research of this article. The views, opinions and positions expressed in this article are the authors’ own and do not reflect the views of any third party.

                    Competing interests:

                    No relevant disclosures.

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                      Multimorbidity among Aboriginal people in New South Wales contributes significantly to their higher mortality

                      Deborah A Randall, Sanja Lujic, Alys Havard, Sandra J Eades and Louisa Jorm
                      Med J Aust 2018; 209 (1): . || doi: 10.5694/mja17.00878
                      Published online: 2 July 2018

                      Abstract

                      Objectives: To compare the prevalence of multimorbidity and its impact on mortality among Aboriginal and non-Aboriginal Australians who had been hospitalised in New South Wales in the previous 10 years.

                      Design, setting and participants: Cohort study analysis of linked NSW hospital (Admitted Patient Data Collection) and mortality data for 5 437 018 New South Wales residents with an admission to a NSW hospital between 1 March 2003 and 1 March 2013, and alive at 1 March 2013.

                      Main outcome measures: Admissions for 30 morbidities during the 10-year study period were identified. The primary outcome was the presence or absence of multimorbidity during the 10-year lookback period; the secondary outcome was mortality in the 12 months from 1 March 2013 to 1 March 2014.

                      Results: 31.5% of Aboriginal patients had at least one morbidity and 16.1% had two or more, compared with 25.0% and 12.1% of non-Aboriginal patients. After adjusting for age, sex, and socio-economic status, the prevalence of multimorbidity among Aboriginal people was 2.59 times that for non-Aboriginal people (95% CI, 2.55–2.62). The prevalence of multimorbidity was higher among Aboriginal people in all age groups, in younger age groups because of the higher prevalence of mental morbidities, and from age 60 because of physical morbidities. The age-, sex- and socio-economic status-adjusted hazard of one-year mortality (Aboriginal v non-Aboriginal Australians) was 2.43 (95% CI, 2.24–2.62), and 1.51 (95% CI, 1.39–1.63) after also adjusting for morbidity count.

                      Conclusions: The prevalence of multimorbidity was higher among Aboriginal than non-Aboriginal patients, and this difference accounted for much of the difference in mortality between the two groups. Evidence-based interventions for reducing multimorbidity among Aboriginal and Torres Strait Islander Australians must be a priority.

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                      • 1 Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW
                      • 2 Sax Institute, Baker IDI Heart and Diabetes Institute, Sydney, NSW


                      Acknowledgements: 

                      This investigation was supported by the National Health and Medical Research Council (573113). We acknowledge the NSW Ministry of Health and NSW Register of Births, Deaths and Marriages for allowing access to the data, and the Centre for Health Record Linkage for conducting the probabilistic linkage of records.

                      Competing interests:

                      No relevant disclosures.

                      • 1. Organisation for Economic Co-operation and Development. Life expectancy at birth (indicator). Paris: OECD, 2015. https://data.oecd.org/healthstat/life-expectancy-at-birth.htm (viewed July 2015).
                      • 2. Australian Bureau of Statistics. 3302.0.55.003. Experimental life tables for Aboriginal and Torres Strait Islander Australians 2005–2007. May 2009. http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/3302.0.55.003Main+Features12005%E2%80%932007 (viewed Apr 2018).
                      • 3. 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.
                      • 4. Pink B, Allbon P. The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples, 2008 (ABS Cat. No. 4704.0; AIHW Cat. No. IHW 21). Canberra: Australian Institute of Health and Welfare, Australian Bureau of Statistics, 2008.
                      • 5. Randall DA, Jorm LR, Lujic S, et al. Disparities in revascularization rates after acute myocardial infarction between Aboriginal and non-Aboriginal people in Australia. Circulation 2013; 127: 811-819.
                      • 6. Katzenellenbogen JM, Knuiman MW, Sanfilippo FM, et al. Prevalence of stroke and coexistent conditions: disparities between indigenous and nonindigenous Western Australians. Int J Stroke 2014; 9: 61-68.
                      • 7. Supramaniam R, Gibberd A, Dillon A, et al. Increasing rates of surgical treatment and preventing comorbidities may increase breast cancer survival for Aboriginal women. BMC Cancer 2014; 14: 163.
                      • 8. Barnett K, Mercer SW, Norbury M, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012; 380: 37-43.
                      • 9. Harrison C, Henderson J, Miller G, Britt H. The prevalence of complex multimorbidity in Australia. Aust N Z J Public Health 2016; 40: 239-244.
                      • 10. Brett T, Arnold-Reed DE, Troeung L, et al. Multimorbidity in a marginalised, street-health Australian population: a retrospective cohort study. BMJ Open 2014; 4: e005461.
                      • 11. Randall DA, Lujic S, Leyland AH, Jorm LR. Statistical methods to enhance reporting of Aboriginal Australians in routine hospital records using data linkage affect estimates of health disparities. Aust N Z J Public Health 2013; 37: 442-449.
                      • 12. Population and Public Health Division. Improved reporting of Aboriginal and Torres Strait Islander peoples on population datasets in New South Wales using record linkage — a feasibility study. Sydney: NSW Ministry of Health, 2012. http://www.health.nsw.gov.au/hsnsw/Publications/atsi-data-linkage-report.pdf (viewed Apr 2018).
                      • 13. Quan H, Sundararajan V, Halfon P, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 2005; 43: 1130-1139.
                      • 14. Diederichs C, Berger K, Bartels DB. The measurement of multiple chronic diseases: a systematic review on existing multimorbidity indices. J Gerontol A Biol Sci Med Sci 2011; 66: 301-311.
                      • 15. Australian Bureau of Statistics. 2033.0.55.001. Socio-economic Indexes for Areas (SEIFA), Australia, 2011: IRSAD. Mar 2013. http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/2033.0.55.001∼2011∼Main%20Features∼IRSAD∼10004 (viewed Mar 2018).
                      • 16. Australian Institute of Health and Welfare. Measuring the social and emotional wellbeing of Aboriginal and Torres Strait Islander peoples (AIHW Cat. No. 24). Canberra: AIHW, 2009.
                      • 17. Wilson M, Stearne A, Gray D, Saggers S. Review of the harmful use of alcohol amongst Indigenous Australians. Australian Indigenous Health Reviews [online] 2010; no. 4. www.healthinfonet.ecu.edu.au/uploads/docs/alcohol-review.pdf (viewed Apr 2018).
                      • 18. Australian Institute of Health and Welfare. 2004 National Drug Strategy Household Survey: detailed findings (AIHW Cat. No. PHE 66). Canberra: AIHW, 2005.
                      • 19. Lujic S, Watson DE, Randall DA, et al. Variation in the recording of common health conditions in routine hospital data: study using linked survey and administrative data in New South Wales, Australia. BMJ Open 2014; 4: e005768.
                      • 20. Nunes BP, Flores TR, Mielke GI, et al. Multimorbidity and mortality in older adults: a systematic review and meta-analysis. Arch Gerontol Geriatr 2016; 67: 130-138.
                      • 21. Mirzaei M, Aspin C, Essue B, et al. A patient-centred approach to health service delivery: improving health outcomes for people with chronic illness. BMC Health Serv Res 2013; 13: 251.
                      • 22. Aspin C, Brown N, Jowsey T, et al. Strategic approaches to enhanced health service delivery for Aboriginal and Torres Strait Islander people with chronic illness: a qualitative study. BMC Health Serv Res 2012; 12: 143.
                      • 23. Davy C, Cass A, Brady J, et al. Facilitating engagement through strong relationships between primary healthcare and Aboriginal and Torres Strait Islander peoples. Aust N Z J Public Health 2016; 40: 535-541.
                      • 24. Clifford A, Shakeshaft A. A bibliometric review of drug and alcohol research focused on Indigenous peoples of Australia, New Zealand, Canada and the United States. Drug Alcohol Rev 2017; 36: 509-522.
                      • 25. Marmot M. Social determinants and the health of Indigenous Australians. Med J Aust 2011; 194: 512-513. <MJA full text>
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