Topics

Abstract

Objective: To systematically review the literature regarding the ability of clinical features to predict respiratory failure in patients with Guillain–Barré syndrome (GBS).

Data sources: We searched the PubMed and Ovid MEDLINE databases with the search terms “guillain barre syndrome” OR “acute inflammatory demyelinating polyneuropathy” OR “acute motor axonal neuropathy” OR “acute motor sensory axonal neuropathy” AND “respiratory failure” OR “mechanical ventilation”. We excluded articles that did not report the results of original research (eg, review articles, letters), were case reports or series (ten or fewer patients), were not available in English, reported research in paediatric populations (16 years of age or younger), or were interventional studies. Article quality was assessed with the Newcastle–Ottawa quality assessment scale.

Data synthesis: Thirty-four relevant studies were identified. Short time from symptom onset to hospital admission (less than 7 days), bulbar (odds ratio [OR], 9.0; 95% CI, 3.94–20.6; P < 0.001) or neck weakness (OR, 6.36; 95% CI, 2.32–17.5; P < 0.001), and severe muscle weakness at hospital admission were associated with increased risk of intubation. Facial weakness (OR, 3.74; 95% CI, 2.05–6.81; P < 0.001) and autonomic instability (OR, 6.40; 95% CI, 2.83–14.5; P < 0.001) were significantly more frequent in patients requiring intubation in our meta-analyses; however, the differences were not statistically significant in individual multivariable analysis studies. Four predictive models have been developed to assess the risk of respiratory failure for patients with GBS, each with good to excellent discriminative power (area under the receiver operating characteristic curve, 0.79–0.96).

Conclusions and relevance: Early identification of GBS patients at risk of respiratory failure could reduce the rates of adverse outcomes associated with delayed intubation. Algorithms that predict a patient’s risk of subsequent respiratory failure at hospital admission appear more reliable than individual clinical variables.

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

Correspondence: cgreen@phcn.vic.gov.au

Competing interests:

No relevant disclosures.

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Editorial

The many costs of homelessness

Adam Steen

Med J Aust 2018; 208 (4): . || doi: 10.5694/mja17.01197
Published online: 5 March 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Health services administration

Social determinants of health

Helping the homeless is a social imperative that benefits the homeless — and the community as a whole

The last few years have seen an upsurge in street homelessness or “rough sleeping” in Australia’s major cities. The homeless population includes more than just “rough sleepers”, however. It is generally accepted that homelessness exists when a person is experiencing insecure or unsafe accommodation, and ranges from situations of sleeping rough, to staying in guest or boarding houses or “couch surfing” with family or friends. Accordingly, homelessness encompasses a spectrum of severity that may last only a short time for most individuals, while others may experience many years of deprivation. While calculating the precise number of homeless people is problematic, we know that 255 657 Australians received support from specialist homelessness services during 2014–15, and almost 7 million nights of accommodation were provided.1

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Institute for Land, Water and Society, Charles Sturt University, Bathurst, NSW

Correspondence: adamsteen@hotmail.com

Competing interests:

No relevant disclosures.

1. Australian Institute of Health and Welfare. Specialist homelessness services 2015–16 [web report]. Dec 2016. www.aihw.gov.au/reports/homelessness-services/specialist-homelessness-services-2014-15/contents/unmet-demand-for-specialist-homelessness-services (viewed Dec 2017).
2. Australian Human Rights Commission. Homelessness is a human rights issue [online article]. 2008. https://www.humanrights.gov.au/our-work/rights-and-freedoms/publications/homelessness-human-rights-issue (viewed Dec 2017).
3. Zaretzky K, Flatau P, Clear A, et al; Australian Housing and Urban Research Institute. The cost of homelessness and the net benefit of homeless programs: a national study. Findings from the Baseline Client Survey (AHURI Final Report No. 205). Melbourne: AHUR, 2013. https://www.ahuri.edu.au/research/final-reports/205 (viewed Dec 2017).
4. Witte E. The case for investing in last resort housing (MSSI Issues Paper No. 10). Melbourne Sustainable Society Institute/The University of Melbourne, 2017. http://sustainable.unimelb.edu.au/case-investing-last-resort-housing (viewed Dec 2017).
5. MacKenzie D, Flatau P, Steen A, Thielking M. The cost of youth homelessness in Australia. Research briefing. 2016. http://www.csi.edu.au/media/uploads/CYHA_FINAL_REPORT_18April2016_v0dqGpT.pdf (viewed Dec 2017).
6. Australian Government, National Mental Health Commission. A contributing life: the 2012 National Report Card on Mental Health and Suicide Prevention. 2012. http://www.mentalhealthcommission.gov.au/our-reports/our-national-report-cards/2012-report-card.aspx (viewed Dec 2017).
7. Nielssen OB, Stone W, Jones NM, et al. Characteristics of people attending psychiatric clinics in inner Sydney homeless hostels. Med J Aust 2018; 208: 169-173.
8. Aubry T, Nelson G, Tsemberis S. Housing First for people with severe mental illness who are homeless: a review of the research and findings from the At Home–Chez soi Demonstration Project. Can J Psychiatry 2015; 60: 467-474.

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Medical education
Key research skills

Guided by the research design: choosing the right statistical test

Alissa Beath and Michael P Jones

Med J Aust 2018; 208 (4): . || doi: 10.5694/mja17.00422
Published online: 5 March 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Statistics, epidemiology and research design

Choosing the right statistical test or model can be baffling for researchers, and if it is not conducted correctly, the results from statistical analyses can be misleading. This article covers some common medical research designs, ranging from simple to more complicated, and provides an outline of which statistical test to apply in each instance. In these contexts, data are collected from a sample that is assumed to be representative of a wider population, and the conclusions drawn from the analyses apply to the wider population.1

Macquarie University, Sydney, NSW

Correspondence: alissa.beath@mq.edu.au

Series Editors

John R Attia

Michael P Jones

Competing interests:

No relevant disclosures.

1. Jones MP, Attia JR. Sampling: how you choose people is as important as how you analyse their data. Med J Aust 2017; 206: 67-68. <MJA full text>
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7. Dobson AJ, Barnett A. An introduction to generalized linear models; 3rd ed. Boca Raton, FL: CRC Press; 2008.

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Perspectives

Oral disease contributes to illness burden and disparities

Steve Kisely, Ratilal Lalloo and Pauline Ford

Med J Aust 2018; 208 (4): . || doi: 10.5694/mja17.00777
Published online: 5 March 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Health occupations

General medicine

Social determinants of health

Oral health cannot be isolated from physical or mental health and should form part of comprehensive care

Dental disease affects 3.9 billion people worldwide, with untreated caries being the most prevalent condition in the Global Burden of Disease Study 2010.1 In spite of this, disparities in oral ill health receive less attention than those in other chronic illnesses, even though dental disease is significantly more prevalent and severe in socially disadvantaged and marginalised groups. These include people on lower incomes, those born outside Australia, Indigenous Australians and people with severe mental illness.2-4 For instance, in comparison with the overall Australian population, Indigenous Australians have 2.77 times the prevalence of untreated dental caries,3 while people with severe mental illness have nearly three times the odds of total tooth loss, the end result of untreated caries and gum disease.4

University of Queensland, Brisbane, QLD

Correspondence: s.kisely@uq.edu.au

Competing interests:

No relevant disclosures.

1. Marcenes W, Kassebaum NJ, Bernabé E, et al. Global burden of oral conditions in 1990-2010: a systematic analysis. J Dent Res 2013; 92: 592-597.
2. Mejia G, Armfield JM, Jamieson LM. Self-rated oral health and oral health-related factors: the role of social inequality. Aust Dent J 2014; 59: 226-233.
3. Schuch HS, Haag DG, Kapellas K, et al. The magnitude of Indigenous and non-Indigenous oral health inequalities in Brazil, New Zealand and Australia. Community Dent Oral Epidemiol 2017; 45: 434-441.
4. Kisely S, Baghaie H, Lalloo R, et al. A systematic review and meta-analysis of the association between poor oral health and severe mental illness. Psychosom Med 2015; 77: 83-92.
5. Kassebaum NJ, Smith AGC, Bernabé E, et al. Global, regional, and national prevalence, incidence, and disability-adjusted life years for oral conditions for 195 countries, 1990–2015: a systematic analysis for the global burden of diseases, injuries, and risk factors J Dent Res 2017; 96: 380-387.
6. Gibney JM, Wright C, Sharma A, et al. The oral health status of older patients in acute care on admission and Day 7 in two Australian hospitals. Age Ageing 2017; 46: 852-856.
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8. Lafon A, Pereira B, Dufour T, et al. Periodontal disease and stroke: a meta-analysis of cohort studies. Eur J Neurol 2014; 21: 1155-1161.
9. D’Aiuto F, Orlandi M, Gunsolley JC. Evidence that periodontal treatment improves biomarkers and CVD outcomes. J Periodontol 2013; 84(4 Suppl): S85-S105.
10. Teshome A, Yitayeh A. The effect of periodontal therapy on glycemic control and fasting plasma glucose level in type 2 diabetic patients: systematic review and meta-analysis. BMC Oral Health 2016; 17: 31.
11. Scannapieco FA, Dasanayake AP, Chhun N. Does periodontal therapy reduce the risk for systemic diseases? Dent Clin North Am 2010; 54: 163-181.
12. Li C, Lv Z, Shi Z, et al. Periodontal therapy for the management of cardiovascular disease in patients with chronic periodontitis. Cochrane Database Syst Rev 2014; (8): CD009197.
13. Matsuyama Y, Aida J, Watt RG, et al. Dental status and compression of life expectancy with disability J Dent Res 2017; 96: 1006-1013.
14. Lawrence D, Hancock KJ, Kisely S. The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: retrospective analysis of population based registers. BMJ 2013; 346: f2539.
15. Cockburn N, Pradhan A, Taing MW, et al. Oral health impacts of medications used to treat mental illness. J Affect Disord 2017; 223: 184-193.
16. Burchell A, Fembacher S, Lewis R, Neil A. ‘Dental as Anything’: inner south community health service dental outreach to people with a mental illness. Aust J Prim Health 2006; 12: 75-82.

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Perspectives

Potential solutions to improve the governance of multicentre health services research

Robyn Clay-Williams, Natalie Taylor and Jeffrey Braithwaite

Med J Aust 2018; 208 (4): . || doi: 10.5694/mja16.01268
Published online: 5 March 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Health services administration

Ethics and law

Building bridges between research groups and the health system will facilitate the production of non-clinical studies

Obtaining institutional consent to conduct health services research in Australia has become onerous and time-consuming,1-8 and thus we present potential solutions to the challenges encountered when seeking approval for large multicentre non-clinical studies. These ideas have been synthesised from what is already known and from our experience obtaining ethics and governance approvals for 60 large public hospitals participating in the Deepening our Understanding of Quality in Australia (DUQuA) study. DUQuA9 is a 3-year Australia-wide, cross-sectional study funded by the National Health and Medical Research Council (NHMRC). This study aims to assess how hospital quality management systems, leadership and culture are related to care delivery and patient outcomes for acute myocardial infarction, stroke and hip fracture.

Australian Institute of Health Innovation, Macquarie University, NSW

Correspondence: robyn.clay-williams@mq.edu.au

Acknowledgements:

DUQuA was funded by the NHMRC Program Grant APP1054146 (CI Braithwaite).

Competing interests:

No relevant disclosures.

1. Boult M, Fitzpatrick K, Maddern G, Fitridge R. A guide to multi-centre ethics for surgical research in Australia and New Zealand. ANZ J Surg 2011; 81: 132-136.
2. De Smit E, Kearns LS, Clarke L, et al. Heterogeneity of human research ethics committees and research governance offices across Australia: an observational study. Australas Med J 2016; 9: 33-39.
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4. Smith-Merry JL, Walton MM. Research governance as a facilitator for ethical and timely research? Learning from the experience of a large government-funded multisite research project. Aust Health Rev 2014; 38: 295-300.
5. Studdert DM, Vu TM, Fox SS, et al. Ethics review of multisite studies: the difficult case of community-based indigenous health research. Med J Aust 2010; 192: 275-280. <MJA full text>
6. Thompson SC, Sanfilippo FM, Briffa TG, Hobbs MST. Towards better health research in Australia — a plea to improve the efficiency of human research ethics committee processes. Med J Aust 2009; 190: 652. <MJA full text>
7. Vajdic CM, Meagher NS, Hicks SC, et al. Governance approval for multisite, non-interventional research: what can Harmonisation of Multi-Centre Ethical Review learn from the New South Wales experience? Intern Med J 2012; 42: 127-131.
8. White V, Bibby H, Green M, et al. Inconsistencies and time delays in site-specific research approvals hinder collaborative clinical research in Australia. Intern Med J 2016; 46: 1023-1029.
9. Taylor N, Clay-Williams R, Hogden E, et al. Deepening our Understanding of Quality in Australia (DUQuA): a study protocol for a nationwide, multilevel analysis of relationships between hospital quality management systems and patient factors. BMJ Open 2015; 5: e010349.
10. National Health and Medical Research Council. List of Human Research Ethics Committees registered with NHMRC. Canberra: NHMRC; 2016. https://www.nhmrc.gov.au/_files_nhmrc/file/health_ethics/human/list_of_hrecs_registered_with_nhmrc_october_2016.pdf (viewed Nov 2017).
11. National Health and Medical Research Council. National Approach to Single Ethical Review of Multi-centre Research. Canberra: NHMRC. https://www.nhmrc.gov.au/health-ethics/national-approach-single-ethical-review (viewed Nov 2017).
12. National Health and Medical Research Council. National Ethics Application Form (NEAF). Canberra: NHMRC. https://www.nhmrc.gov.au/health-ethics/national-ethics-application-form-neaf (viewed Nov 2017).
13. National Health and Medical Research Council. Research governance handbook: guidance for the national approach to single ethical review, December 2011. Canberra: NHMRC; 2011. https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/ethics/human_research/12._research_governance_handbook_120203_0.pdf (viewed Nov 2017).
14. Department of Health Western Australia. Multi-centre research [website]. https://rgs.health.wa.gov.au/Pages/Multi-centre-Research.aspx (viewed Dec 2017).

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Editorials

Don’t lose sight: last drinks laws reduce violent assaults

Diana Egerton-Warburton

Med J Aust 2018; 208 (4): . || doi: 10.5694/mja17.01111
Published online: 26 February 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Environment and public health

Substance‐related disorders

The evidence that reducing trading hours reduces alcohol-related violence is compelling

Alcohol-related violence has a large impact on the Australian health care system and on society. Emergency departments (EDs) and acute surgical services are the frontline in dealing with these presentations. A prospective study of eight EDs in Australia and New Zealand found that almost one in ten presentations are alcohol-related throughout the week.1 Further, ED clinicians frequently experience violence and aggression inflicted by patients affected by alcohol.2

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

Correspondence: diana.egertonwarburton@monashhealth.org

Competing interests:

No relevant disclosures.

1. Egerton-Warburton D, Gosbell A, Moore K, et al. Alcohol-related harm in emergency departments: a prospective, multicenter study. Addiction 2018; https://doi.org/10.1111/add.14109 [Epub ahead of print].
2. Egerton-Warburton D, Gosbell A, Wadsworth A, et al. Perceptions of Australasian emergency department staff of the impact of alcohol-related presentations. Med J Aust 2016; 204: 155. <MJA full text>
3. Holmes RF, Lung T, Fulde GWO, Fraser CL. Fewer orbital fractures treated at St Vincent’s Hospital after lock-out laws introduced in Sydney. Med J Aust 2018; 208: 174.
4. Egerton-Warburton D, Gosbell A, Wadsworth A, et al. Survey of alcohol-related presentations to Australasian emergency departments. Med J Aust 2014; 201: 584-587. <MJA full text>
5. Fulde GW, Smith M, Forster LS. Presentations with alcohol-related serious injury to a major Sydney trauma hospital after 2014 changes to liquor laws. Med J Aust 2015; 203: 366. <MJA full text>
6. Menéndez P, Kypri K, Weatherburn D. The effect of liquor licensing restrictions on assault: a quasi-experimental study in Sydney, Australia. Addiction 2017; 112: 261-268.
7. Kypri K, McElduff P, Miller P. Restrictions in pub closing times and lockouts in Newcastle, Australia five years on. Drug Alcohol Rev 2014; 33: 323-326.
8. Rossow I, Norstrom T. The impact of small changes in bar closing hours on violence. The Norwegian experience from 18 cities. Addiction 2012; 107: 530-537.
9. Chikritzhs T, Stockwell T. The impact of later trading hours for hotels on levels of impaired driver road crashes and driver breath alcohol levels. Addiction 2006; 101: 1254-1264.
10. Callinan, IDF. Review of amendments to the liquor act 2007 (NSW). Reviews under clause 47 to Schedule 1 of the Liquor Act, clause 5O of the Liquor Regulation 2008, and at the request of the Executive Government. 13 Sept 2016. http://www.liquorandgaming.nsw.gov.au/Documents/public-consultation/independent%20liquor%20law%20review/Liquor-Law-Review-Report.pdf (viewed Nov 2017).
11. Sivarajasingam V, Shepherd JP, Newcombe RG. Why public health must contribute to reduce violence. BMJ 2011; 343: d4453.
12. Droste N, Miller P, Baker M. Emergency department data sharing to reduce alcohol-related violence: a systematic review of the feasibility and effectiveness of community-level interventions. Emerg Med Australas 2014; 26: 326-335.
13. Florence C, Shepherd J, Brennan I, Simon R. An economic evaluation of anonymised information sharing in a partnership between health services, police and local government for preventing violence-related injury. Inj Prev 2014; 20: 108-114.
14. Parliament of Queensland. Tackling Alcohol-Fuelled Violence Legislation Amendment Act 2016 (Act No. 4 of 2016). https://www.legislation.qld.gov.au/view/pdf/asmade/act-2016-004 (viewed Nov 2017).

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Guideline summary

Updated evidence-based clinical practice guidelines for the diagnosis and management of melanoma: definitive excision margins for primary cutaneous melanoma

Michael J Sladden, Omgo E Nieweg, Julie Howle, Brendon J Coventry and John F Thompson

Med J Aust 2018; 208 (3): . || doi: 10.5694/mja17.00278
Published online: 19 February 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Skin and connective tissue diseases

Surgical procedures, operative

General medicine

Abstract

Introduction: Definitive management of primary cutaneous melanoma consists of surgical excision of the melanoma with the aim of curing the patient. The melanoma is widely excised together with a safety margin of surrounding skin and subcutaneous tissue, after the diagnosis and Breslow thickness have been established by histological assessment of the initial excision biopsy specimen. Sentinel lymph node biopsy should be discussed for melanomas ≥ 1 mm thickness (≥ 0.8 mm if other high risk features) in which case lymphoscintigraphy must be performed before wider excision of the primary melanoma site. The 2008 evidence-based clinical practice guidelines for the management of melanoma (http://www.cancer.org.au/content/pdf/HealthProfessionals/ClinicalGuidelines/ClinicalPracticeGuidelines-ManagementofMelanoma.pdf) are currently being revised and updated in a staged process by a multidisciplinary working party established by Cancer Council Australia. The guidelines for definitive excision margins for primary melanomas have been revised as part of this process.

Main recommendations: The recommendations for definitive wide local excision of primary cutaneous melanoma are:

melanoma in situ: 5–10 mm margins
invasive melanoma (pT1) ≤ 1.0 mm thick: 1 cm margins
invasive melanoma (pT2) 1.01–2.00 mm thick: 1–2 cm margins
invasive melanoma (pT3) 2.01–4.00 mm thick: 1–2 cm margins
invasive melanoma (pT4) > 4.0 mm thick: 2 cm margins

Changes in management as a result of the guideline: Based on currently available evidence, excision margins for invasive melanoma have been left unchanged compared with the 2008 guidelines. However, melanoma in situ should be excised with 5–10 mm margins, with the aim of achieving complete histological clearance. Minimum clearances from all margins should be assessed and stated. Consideration should be given to further excision if necessary; positive or close histological margins are unacceptable.

1 University of Tasmania, Launceston, TAS
2 Melanoma Institute Australia, Sydney, NSW
3 University of Sydney, Sydney, NSW
4 Westmead Hospital, Sydney, NSW
5 Royal Adelaide Hospital, Adelaide, SA

Correspondence: m.sladden@doctors.org.uk

Acknowledgements:

The guidelines were developed by Cancer Council Australia and Melanoma Institute Australia with financial support from Skin Cancer College Australasia. We acknowledge the Cancer Council Australia and Melanoma Institute Australia project staff, in particular Lani Teddy and Jackie Buck, who were involved in the systematic review.

Competing interests:

No relevant disclosures.

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Narrative review

Cannabis for paediatric epilepsy: challenges and conundrums

Kerrie-Anne Chen, Michelle A Farrar, Michael Cardamone and John A Lawson

Med J Aust 2018; 208 (3): . || doi: 10.5694/mja17.00699
Published online: 19 February 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Nervous system diseases

Pharmaceutical preparations

Pediatric medicine

Summary

Research is expanding for the use of cannabidiol as an anticonvulsant drug. The mechanism of cannabidiol in paediatric epilepsy is unclear but is thought to play a role in modulation of synaptic transmission.
Evidence for its efficacy in treating epilepsy is limited but growing, with a single pharmaceutical company-funded randomised double-blind controlled trial in children with Dravet syndrome.
Progress towards the use of medicinal cannabinoids incorporates a complex interplay of social influences and political and legal reform.
Access to unregistered but available cannabidiol in Australia outside of clinical trials and compassionate access schemes is state dependent and will require Therapeutic Goods Administration approval, although the cost may be prohibitive.
Further clinical trials are needed to clearly define efficacy and safety, particularly long term.

1 Sydney Children's Hospital, Randwick, Sydney, NSW
2 UNSW Sydney, Sydney, NSW

Correspondence: john.lawson@health.nsw.gov.au

Competing interests:

John Lawson is the lead investigator in the NSW Ministry of Health-funded medical cannabis trials.

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Predictors of respiratory failure in patients with Guillain–Barré syndrome: a systematic review and meta-analysis

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The many costs of homelessness

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Potential solutions to improve the governance of multicentre health services research

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Don’t lose sight: last drinks laws reduce violent assaults

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Updated evidence-based clinical practice guidelines for the diagnosis and management of melanoma: definitive excision margins for primary cutaneous melanoma

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Cannabis for paediatric epilepsy: challenges and conundrums

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Administrative encounters in general practice: low value or hidden value care?

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Maternal overweight and obesity: where to from here?

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Predictors of respiratory failure in patients with Guillain–Barré syndrome: a systematic review and meta-analysis

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The many costs of homelessness

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Guided by the research design: choosing the right statistical test

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Oral disease contributes to illness burden and disparities

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Potential solutions to improve the governance of multicentre health services research

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Don’t lose sight: last drinks laws reduce violent assaults

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Updated evidence-based clinical practice guidelines for the diagnosis and management of melanoma: definitive excision margins for primary cutaneous melanoma

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Cannabis for paediatric epilepsy: challenges and conundrums

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Administrative encounters in general practice: low value or hidden value care?

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Maternal overweight and obesity: where to from here?

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Pagination