Topics

Abstract

Objectives: To assess the incidence and multiplicity of keratinocyte cancers (basal cell carcinoma [BCC] and squamous cell carcinoma [SCC]) excised in Australia, and to examine variations by age, sex, state, and prior skin cancer history.

Design: Analysis of individual-level Medicare data for keratinocyte cancer treatments (identified by eight specific MBS item codes) during 2011–2014. Histological data from the QSkin prospective cohort study were analysed to estimate BCC and SCC incidence.

Setting: A 10% systematic random sample of all people registered with Medicare during 1997–2014.

Participants: People aged at least 20 years in 2011 who made at least one claim for any MBS medical service during 2011–2014 (1 704 193 individuals).

Main outcome measures: Age-standardised incidence rates (ASRs) and standardised incidence ratios (SIRs).

Results: The person-based incidence of keratinocyte cancer excisions in Australia was 1531 per 100 000 person-years; incidence increased with age, and was higher for men than women (SIR, 1.43; 95% CI, 1.42–1.45). Lesion-based incidence was 3154 per 100 000 person-years. The estimated ASRs for BCC and SCC were 770 per 100 000 and 270 per 100 000 person-years respectively. During 2011–2014, 3.9% of Australians had one keratinocyte cancer excised, 2.7% had more than one excised; 74% of skin cancers were excised from patients who had two or more lesions removed. Multiplicity was strongly correlated with age; most male patients over 70 were treated for multiple lesions. Keratinocyte cancer incidence was eight times as high among people with a prior history of excisions as among those without.

Conclusions: The incidence and multiplicity of keratinocyte cancer in Australia are very high, causing a large disease burden that has not previously been quantified.

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QIMR Berghofer Medical Research Institute, Brisbane, QLD

Correspondence: david.whiteman@qimrberghofer.edu.au

Acknowledgements:

We are grateful to Jonathan Davies and Archie De Guzman (QIMR Berghofer IT Department) for their help in obtaining and managing Medicare data and extracting the relevant subset for this analysis. This work is supported by the National Health and Medical Research Council (grant numbers 1073898, 1058522). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests:

No relevant disclosures.

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Editorials

Whither melanoma in Australia?

B Mark Smithers, Jeff Dunn and H Peter Soyer

Med J Aust 2017; 207 (8): . || doi: 10.5694/mja17.00740
Published online: 16 October 2017

ARTICLE
AUTHORS
REFERENCES

Topics

Skin and connective tissue diseases

Neoplasms

To improve melanoma outcomes, the focus on prevention, early detection and new treatment strategies must continue

Over the past 5 years, we have seen a dramatic response to the intense biological research into late-stage, metastatic melanoma, with therapies targeting melanoma metastases and improving an individual’s immune response to the disease. This has led to an improvement in progression-free and overall survival in a group of patients who would have previously been treated with drugs that had little effect. Intense research and clinical trials continue with the aim of identifying patients most likely to respond, as well as exploring new combinations of therapies with this new paradigm for melanoma treatment.

1 University of Queensland, Brisbane, QLD
2 Princess Alexandra Hospital, Brisbane, QLD
3 Institute for Resilient Regions, University of Southern Queensland, Toowoomba, QLD
4 Cancer Council Queensland, Brisbane, QLD
5 Dermatology Research Centre, The University of Queensland Diamantina Institute, Brisbane, QLD

Correspondence: m.smithers@uq.edu.au

Competing interests:

No relevant disclosures.

1. Whiteman DC, Green AC, Olsen CM. The growing burden of invasive melanoma: projections of incidence rates and numbers of new cases in six susceptible populations through 2031. J Invest Dermatol 2016; 136: 1161-1171.
2. Green AC, Baade P, Coory M, et al. Population-based 20-year survival among people diagnosed with thin melanomas in Queensland, Australia. J Clin Oncol 2012; 30: 1462-1467.
3. Davis NC. Cutaneous melanoma: the Queensland experience. Curr Probl Surg 1976; 13: 1-63.
4. Gordon LG, Rowell D. Health system costs of skin cancer and cost-effectiveness of skin cancer prevention and screening: a systematic review. Eur J Cancer Prev 2015; 24: 141-149.
5. Ainger SA, Jagirdar K, Lee KJ, et al. Skin pigmentation genetics for the clinic. Dermatology 2017; 233: 1-15.
6. Janda M, Soyer HP. Greater precision in melanoma prevention. JAMA Dermatol 2017; 153: 18-19.
7. Janda M, Soyer HP. Automated diagnosis of melanoma. Med J Aust 2017; 207: 361-362.
8. Mar VJ, Chamberlain AJ, Kelly JW, et al. Clinical practice guidelines for the diagnosis and management of melanoma: melanomas that lack classical clinical features. Med J Aust 2017; 207: 348-350.
9. Pan Y, Adler NR, Wolfe R, et al. Nodular melanoma is less likely than superficial spreading melanoma to be histologically associated with a naevus. Med J Aust 2017; 207: 333-338.
10. Australian Institute of Health and Welfare. Skin cancer in Australia (AIHW Cat. No. CAN 96) Canberra: AIHW 2016.

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Perspectives

The rationale for action to end new cases of rheumatic heart disease in Australia

Rosemary Wyber, Judith M Katzenellenbogen, Glenn Pearson and Michael Gannon

Med J Aust 2017; 207 (8): . || doi: 10.5694/mja17.00246
Published online: 16 October 2017

ARTICLE
AUTHORS
REFERENCES

Topics

Cardiovascular diseases

Indigenous health

Closing the gap in cardiovascular health

On 25 November 2016, the Australian Medical Association (AMA) launched their annual Report Card on Indigenous Health entitled A call to action to prevent new cases of rheumatic heart disease in Indigenous Australia by 2031.1 In 14 years of AMA report cards, this is the first to focus on a single pathology. The choice of rheumatic heart disease (RHD) is telling: the disease is a striking marker of inequality, a novel lens for considering health systems and a feasible target for definitive disease control.

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1 Telethon Kids Institute, University of Western Australia, Perth, WA
2 Western Australian Centre for Rural Health, University of Western Australia, Perth, WA
3 Australian Medical Association, Canberra, ACT

Correspondence: rosemary.wyber@telethonkids.org.au

Acknowledgements:

The founding members of the END RHD Coalition are the END RHD CRE, the AMA (President Michael Gannon), the National Aboriginal Community Controlled Health Organisation (Chief Executive Officer [CEO] Patricia Turner), RHDAustralia (Director Bart Currie), Aboriginal Medical Services Alliance Northern Territory (CEO John Paterson) and the National Heart Foundation of Australia (CEO John Kelly).

Competing interests:

No relevant disclosures.

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8. Roberts K, Maguire G, Brown A, et al. Echocardiographic screening for rheumatic heart disease in high low risk Australian children. Circulation 2014; 129: 1953-1961.
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Guideline summary

Clinical practice guidelines for the diagnosis and management of melanoma: melanomas that lack classical clinical features

Victoria J Mar, Alex J Chamberlain, John W Kelly, William K Murray and John F Thompson

Med J Aust 2017; 207 (8): . || doi: 10.5694/mja17.00123
Published online: 9 October 2017

ARTICLE
AUTHORS
REFERENCES

Topics

Skin and connective tissue diseases

General medicine

Abstract

Introduction: A Cancer Council Australia multidisciplinary working group is currently revising and updating the 2008 evidence-based clinical practice guidelines for the management of cutaneous melanoma. While there have been many recent improvements in treatment options for metastatic melanoma, early diagnosis remains critical to reducing mortality from the disease. Improved awareness of the atypical presentations of this common malignancy is required to achieve this. A chapter of the new guidelines was therefore developed to aid recognition of atypical melanomas.

Main recommendations: Because thick, life-threatening melanomas may lack the more classical ABCD (asymmetry, border irregularity, colour variegation, diameter > 6 mm) features of melanoma, a thorough history of the lesion with regard to change in morphology and growth over time is essential. Any lesion that is changing in morphology or growing over a period of more than one month should be excised or referred for prompt expert opinion.

Changes in management as a result of the guidelines: These guidelines provide greater emphasis on improved recognition of the atypical presentations of melanoma, in particular nodular, desmoplastic and acral lentiginous subtypes, with particular awareness of hypomelanotic and amelanotic lesions.

1 Victorian Melanoma Service, Alfred Health, Melbourne, VIC
2 Monash University, Melbourne, VIC
3 Peter MacCallum Cancer Centre, Melbourne, VIC
4 Melanoma Institute Australia, Sydney, NSW
5 University of Sydney, Sydney, NSW

Correspondence: victoria.mar@monash.edu

Acknowledgements:

We thank Laura Wuellner, Jutta von Dincklage and Jackie Buck from the Cancer Council Australia Clinical Guidelines Network for their assistance in this work. Development of the new Clinical Practice Guidelines for the Diagnosis and Management of Melanoma was funded by Cancer Council Australia and Melanoma Institute Australia, with additional support from the Skin Cancer College Australasia.

Competing interests:

No relevant disclosures.

1. Smithson SL, Pan Y, Mar V. Differing trends in thickness and survival between nodular and non-nodular primary cutaneous melanoma in Victoria, Australia. Med J Aust 2015; 203: 20. <MJA full text>
2. Baade PD, English DR, Youl PH, et al. The relationship between melanoma thickness and time to diagnosis in a large population-based study. Arch Dermatol 2006; 142: 1422-1427.
3. Criscione VD, Weinstock MA. Melanoma thickness trends in the United States, 1988-2006. J Invest Dermatol 2010; 130: 793-797.
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10. Chamberlain AJ, Fritschi L, Giles GG, et al. Nodular type and older age as the most significant associations of thick melanoma in Victoria, Australia. Arch Dermatol 2002; 138: 609-614.
11. Kelly JW, Chamberlain AJ, Staples MP, McAvoy B. Nodular melanoma. No longer as simple as ABC. Aust Fam Physician 2003; 32: 706-709.
12. Lin MJ, Mar V, McLean C, et al. Diagnostic accuracy of malignant melanoma according to subtype. Australas J Dermatol 2014; 55: 35-42.
13. Liu WD, Dowling JP, Murray WK, et al. Amelanotic primary cutaneous melanoma – clinical associations and dynamic evolution. Australas J Dermatol 2006; 47(Suppl 1): A1.
14. Menzies SW, Kreusch J, Byth K, et al. Dermoscopic evaluation of amelanotic and hypomelanotic melanoma. Arch Dermatol 2008; 144: 1120-1127.
15. Chamberlain AJ, Fritschi L, Kelly JW. Nodular melanoma: patients’ perceptions of presenting features and implications for earlier detection. J Am Acad Dermatol 2003; 48: 694-701.
16. Phan A, Dalle S, Touzet S, et al. Dermoscopic features of acral lentiginous melanoma in a large series of 110 cases in a white population. Br J Dermatol 2010; 162: 765-771.
17. McCormack CJ, Conyers RK, Scolyer RA, et al. Atypical Spitzoid neoplasms: a review of potential markers of biological behavior including sentinel node biopsy. Melanoma Res 2014; 24: 437-447.
18. Pizzichetta MA, Talamini R, Stanganelli I, et al. Amelanotic/hypomelanotic melanoma: clinical and dermoscopic features. Br J Dermatol 2004; 150: 1117-1124.
19. Menzies SW, Moloney FJ, Byth K, et al. Dermoscopic evaluation of nodular melanoma. JAMA Dermatol 2013; 149: 699-709.
20. Betti R, Martino P, Vergani R, et al. Nodular melanomas: analysis of the casistic and relationship with thick melanomas and diagnostic delay. J Dermatol 2008; 35: 643-650.
21. Richard MA, Grob JJ, Avril MF, et al. Delays in diagnosis and melanoma prognosis (II): the role of doctors. Int J Cancer 2000; 89: 280-285.
22. Richard MA, Grob JJ, Avril MF, et al. Delays in diagnosis and melanoma prognosis (I): the role of patients. Int J Cancer 2000; 89: 271-279.
23. Lin MJ, Mar V, McLean C, Kelly JW. An objective measure of growth rate using partial biopsy specimens of melanomas that were initially misdiagnosed. J Am Acad Dermatol 2014; 71: 691-697.
24. Liu W, Dowling JP, Murray WK, et al. Rate of growth in melanomas: characteristics and associations of rapidly growing melanomas. Arch Dermatol 2006; 142: 1551-1558.
25. Martorell-Calatayud A, Nagore E, Botella-Estrada R, et al. Defining fast-growing melanomas: reappraisal of epidemiological, clinical, and histological features. Melanoma Res 2011; 21: 131-138.
26. Tejera-Vaquerizo A, Barrera-Vigo MV, Lopez-Navarro N, Herrera-Ceballos E. Growth rate as a prognostic factor in localized invasive cutaneous melanoma. J Eur Acad Dermatol Venereol 2010; 24: 147-154.

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Narrative review

Diagnosis and management of irritable bowel syndrome: a guide for the generalist

Ecushla C Linedale and Jane M Andrews

Med J Aust 2017; 207 (7): . || doi: 10.5694/mja17.00457
Published online: 2 October 2017

ARTICLE
AUTHORS
REFERENCES

Topics

Digestive system diseases

General medicine

Summary

Irritable bowel syndrome (IBS) and other functional gastrointestinal disorders (FGIDs) are so prevalent they cannot reasonably have their diagnoses and management based within specialty care. However, delayed diagnosis, lengthy wait times for specialist review, overinvestigation and lack of clear diagnostic communication are common.
The intrusive symptoms of IBS and other FGIDs impair patient functioning and reduce quality of life, and come with significant costs to individual patients and the health care system, which could be reduced with timely diagnosis and effective management.
IBS, in particular, is no longer a diagnosis of exclusion, and there are now effective dietary and psychological therapies that may be accessed without specialist referral.
The faecal calprotectin test is widely available, yet not on the Medical Benefits Schedule, and a normal test result reliably discriminates between people with IBS and patients who warrant specialist referral.

1 University of Adelaide, Adelaide, SA
2 Royal Adelaide Hospital, Adelaide, SA

Correspondence: Jane.Andrews@sa.gov.au

Competing interests:

Jane Andrews has worked as a speaker, consultant and advisory board member for Abbott, AbbVie, Allergan, Celgene, Ferring Pharmaceuticals, Takeda Pharmaceuticals, MSD, Shire, Janssen, Hospira and Pfizer; and has received research funding from Abbott, AbbVie, Ferring Pharmaceuticals, MSD, Shire and Janssen.

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Narrative review

Diagnosing, monitoring and managing behavioural variant frontotemporal dementia

Olivier Piguet, Fiona Kumfor and John Hodges

Med J Aust 2017; 207 (7): . || doi: 10.5694/mja16.01458
Published online: 2 October 2017

ARTICLE
AUTHORS
REFERENCES

Topics

Nervous system diseases

Mental disorders

Summary

Behavioural variant frontotemporal dementia is characterised by insidious changes in personality and interpersonal conduct that reflect progressive disintegration of the neural circuits involved in social cognition, emotion regulation, motivation and decision making.
The underlying pathology is heterogeneous and classified according to the presence of intraneuronal inclusions of tau, TDP-43 or, occasionally, fused in sarcoma proteins. Biomarkers to detect these histopathological changes in life are increasingly important with the development of disease-modifying drugs.
A number of gene abnormalities have been identified, the most common being an expansion in the C9orf72 gene, which together account for most familial cases.
The 2011 international consensus criteria propose three levels of diagnostic certainty: possible, probable and definite. Detailed history taking from family members to elicit behavioural features underpins the diagnostic process, with support from neuropsychological testing designed to detect impairment in decision making, emotion processing and social cognition. Brain imaging is important for increasing the level of diagnosis certainty over time. Carer education and support remain of paramount importance.

1 Brain and Mind Centre, University of Sydney, Sydney, NSW
2 School of Psychology, University of Sydney, Sydney, NSW
3 Sydney Medical School, University of Sydney, Sydney, NSW

Correspondence: olivier.piguet@sydney.edu.au

Acknowledgements:

Olivier Piguet is supported by a National Health and Medical Research Council (NHMRC) Senior Research Fellowship (APP1103258). Fiona Kumfor is supported by an NHMRC–Australian Research Council Dementia Research Development Fellowship (APP1097026).

Competing interests:

No relevant disclosures.

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Short report

Adverse events following vaccination of older people may be under-reported

Hazel J Clothier, Nigel W Crawford, Melissa Russell and Jim P Buttery

Med J Aust 2017; 207 (7): . || doi: 10.5694/mja16.01371
Published online: 2 October 2017

ARTICLE
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REFERENCES

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Health services administration

Gerontology

Infectious diseases

Environment and public health

Adverse events following immunisation (AEFIs) in Australia are monitored by diverse jurisdictional passive surveillance systems that report to the national database, established primarily for detecting safety problems with childhood vaccinations. Supplementary, active AEFI surveillance systems, such as AusVaxSafety (operated by the National Centre for Immunisation Research and Surveillance) request AEFI information by automated SMS and email messages after selected vaccinations. Understanding AEFI reporting patterns for older people is important for identifying safety problems in this group, particularly following the introduction of a zoster vaccine program targeting 70–79-year-old people in November 2016.1

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1 SAEFVIC, Murdoch Children's Research Institute, Melbourne, VIC
2 University of Melbourne, Melbourne, VIC
3 Monash Children's Hospital, Melbourne, VIC
4 Monash Centre for Health Research and Implementation, Monash University, Melbourne, VIC

Correspondence: hazel.clothier@mcri.edu.au

Acknowledgements:

We thank the immunisation nurses and staff of SAEFVIC who receive and review the AEFI reports, and Heath Kelly for his editorial guidance. SAEFVIC is funded by the Department of Health and Human Services, Victoria. Hazel Clothier receives an Australian Government Research Training Program Scholarship.

Competing interests:

No relevant disclosures.

1. National Centre for Immunisation Research & Surveillance. Zoster vaccine for Australian adults: information for immunisation providers [factsheet]. Oct 2016. http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/zoster-vaccine-fact-sheet.pdf (accessed Jan 2017).
2. Clothier HJ, Crawford NW, Kempe A, Buttery JP. Surveillance of adverse events following immunisation: the model of SAEFVIC, Victoria. Commun Dis Intell Q Rep 2011; 35: 294-298.
3. Gold MS, Balakrishnan MR, Amarasinghe A, MacDonald NE. An approach to death as an adverse event following immunization. Vaccine 2016; 34: 212-217.
4. Dey A, Wang H, Quinn HE, et al. Surveillance of adverse events following immunisation in Australia annual report, 2014. Commun Dis Intell Q Rep 2016; 40: E377-E390.
5. Clothier HJ, Selvaraj G, Easton ML, et al. Consumer reporting of adverse events following immunization. Hum Vacc Immunother 2014; 10: 3726-3730.
6. National Centre for Immunisation Research and Surveillance. AusVaxSafety [webpage]. Updated May 2017. http://www.ncirs.edu.au/vaccine-safety/ausvaxsafety/ (accessed July 2017).

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Editorials

Improving organ donation rates and transplantation in Australia

Richard DM Allen and Henry CC Pleass

Med J Aust 2017; 207 (7): . || doi: 10.5694/mja17.00590
Published online: 2 October 2017

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Health services administration

Social determinants of health

Broader acceptance of organs from circulatory death donors would increase donor rates significantly

The initiative funded by the Federal Government in 2009 to improve both the identification of potential deceased organ donors and family consent rates has dramatically changed the prospects for Australians with end-stage organ failure. The subsequent establishment of a coordinated DonateLife network, with more than 150 medical and nursing staff charged with identifying potential organ donors, has led to the donation rate increasing over the past 5 years from 11.4 to 20.9 donors per million population (pmp) in 2016. Record numbers of organ transplants and reduced waiting times for transplantation have resulted.1,2

1 Bosch Institute, University of Sydney, Sydney, NSW
2 Westmead Hospital, Sydney, NSW

Correspondence: richard.allen@sydney.edu.au

Competing interests:

No relevant disclosures.

1. Australia and New Zealand Organ Donation Registry. Summary of organ donation: organs retrieved and actually transplanted. Dec 2016. http://www.anzdata.org.au/anzod/updates/20170208_ANZOD_DonorSummaryReport_2016December.pdf (accessed Aug 2017).
2. Australia and New Zealand Organ Donation Registry. Monthly report on deceased organ donation in Australia. Dec 2016. http://www.anzdata.org.au/anzod/updates/ANZOD2016summary.pdf (accessed Aug 2017).
3. Rakhra SS, Opdam HI, Gladkis L, et al. Untapped potential in Australian hospitals for organ donation after circulatory death. Med J Aust 2017; 207: 294-301.
4. Cao Y, Shahrestani S, Chew HC, et al. Donation after circulatory death for liver transplantation: a meta-analysis on the location of life support withdrawal affecting outcomes. Transplantation 2016; 100: 1513-1524.
5. Levvey BJ, Harkess M, Hopkins P, et al. Excellent clinical outcomes from a national donation after cardiac death lung transplant collaborative. Am J Transplant 2012; 12: 2406-2413.
6. Dhittal KK, Iyer A, Connellan M, et al. Adult heart transplantation with distant procurement and ex-vivo preservation of donor hearts after circulatory death: a case series. Lancet 2015; 385: 2585-2591.

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The incidence and multiplicity rates of keratinocyte cancers in Australia

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Whither melanoma in Australia?

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The rationale for action to end new cases of rheumatic heart disease in Australia

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Clinical practice guidelines for the diagnosis and management of melanoma: melanomas that lack classical clinical features

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Diagnosis and management of irritable bowel syndrome: a guide for the generalist

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Diagnosing, monitoring and managing behavioural variant frontotemporal dementia

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Adverse events following vaccination of older people may be under-reported

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Improving organ donation rates and transplantation in Australia

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Unravelling the evidence for prescribing medicinal cannabis

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Health care variation: the next challenge for clinical colleges

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The incidence and multiplicity rates of keratinocyte cancers in Australia

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Whither melanoma in Australia?

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Clinical practice guidelines for the diagnosis and management of melanoma: melanomas that lack classical clinical features

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Diagnosis and management of irritable bowel syndrome: a guide for the generalist

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Diagnosing, monitoring and managing behavioural variant frontotemporal dementia

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Adverse events following vaccination of older people may be under-reported

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Improving organ donation rates and transplantation in Australia

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Unravelling the evidence for prescribing medicinal cannabis

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Pagination