Topics

A new approach better informs women and doctors about what assisted reproductive technologies can achieve in 2017

Since the first Australian conceived by in vitro fertilisation (IVF) was born in 1980, this and other assisted reproductive technologies (ARTs) have come a long way in scope, availability, and success rates. About 4% of all Australian births are now made possible by ART,1 equivalent to one child in every classroom.

1 Centenary Hospital for Women and Children, Canberra, ACT
2 Australian National University, Canberra, ACT
3 James Cook University, Cairns, QLD

Correspondence: caroline.decosta@jcu.edu.au

Competing interests:

Stephen Robson is a paid member of the Medical Benefits Schedule Review and provides in vitro fertilisation services, but does not own any shares in an IVF unit.

1. Australian Institute of Health and Welfare. Australia’s mothers and babies 2013 — in brief (AIHW Cat. No. PER 72; Perinatal Statistics Series No. 31). Canberra: AIHW, 2015.
2. Chambers GM, Huang VP, Sullivan EA, et al. The impact of consumer affordability on access to assisted reproductive technologies and embryo transfer practices: an international analysis. Fertil Steril 2014; 101: 191-198.
3. Clark A. National fertility study 2006. Australians’ experience and knowledge of fertility issues (PowerPoint). www.fertilitysociety.com.au/wp-content/uploads/preservation-of-fertility-presentation-2006.ppt#1 (accessed May 2017).
4. Boivin J, Bunting L, Collins J, Nygren K. International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care. Hum Reprod 2007; 22: 1506-1512.
5. Collins J. Cost-effectiveness of in vitro fertilization. Semin Reprod Med 2001; 19: 279-290.
6. Mladovsky P, Sorenson C. Public financing of IVF: a review of policy rationales. Health Care Anal 2010; 18: 113-128.
7. Chambers GM, Zhu R, Hoang V, Illingworth PJ. A reduction in public health funding for fertility treatment — an econometric analysis of access to treatment and savings to government. BMC Health Serv Res 2012; 12: 142.
8. Chambers GM, Hoang VP, Illingworth PJ. Socioeconomic disparities in access to ART treatment and the differential impact of a policy that increased consumer costs. Hum Reprod 2013; 28: 3111-3117.
9. Chambers GM, Paul RC, Harris K, et al. Assisted reproductive technology in Australia and New Zealand: cumulative live birth rates as measures of success. Med J Aust 2017; 207: 114-118.
10. Dahdouh EM, Balayla J, Audibert F, et al. Technical update: preimplantation genetic diagnosis and screening. J Obstet Gynaecol Can 2015; 37: 451-463.
11. Australian Institute of Health and Welfare. 25 years of health expenditure in Australia 1989–0 to 2013–14 (AIHW Cat. No. HWE 63; Health and Welfare Expenditure Series No. 56). Canberra: AIHW, 2016.
12. Boxall A. What are we doing to ensure the sustainability of the health system? (Research paper no. 4, 2011–12). Parliamentary Library, 18 Nov 2011. http://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/rp/rp1112/12rp04 (accessed May 2017).

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Medical education

How to measure a QT interval

Kathryn Waddell-Smith, Robert M Gow and Jonathan R Skinner

Med J Aust 2017; 207 (3): . || doi: 10.5694/mja16.00442
Published online: 7 August 2017

ARTICLE
AUTHORS
REFERENCES

Topics

Medical genetics

Cardiovascular diseases

A standard approach in QT measurement improves communication between clinicians

An abnormally prolonged QT interval is associated with an increased risk of sudden cardiac death.1 Some professional bodies recommend national population-based screening programs to detect QT prolongation.2 Familial long QT syndrome (LQTS) may remain undetected because of misdiagnosis (eg, as a seizure disorder)3 or through failure to measure the QT interval correctly.4 Psychiatrists fear the QT prolongation caused by many psychotropic medications,5 and it may also be seen during periods of hypothermia; electrolyte imbalance (such as hypokalaemia, hypomagnesaemia and hypocalcaemia); in the setting of raised intracranial pressure or post-cardiac arrest; with other medications, such as type 1A, 1C and III antiarrhythmic agents; and with antihistamines and macrolide antibiotics.

1 Starship Children's Health, Auckland, New Zealand
2 Children's Hospital of Eastern Ontario, Ottawa, Canada

Correspondence: jskinner@adhb.govt.nz

Competing interests:

Jon Skinner has no relevant disclosures. Kathryn Waddell-Smith is supported by grants from the Green Lane Research and Educational Fund and the National Heart Foundation, New Zealand.

1. Priori SG, Wilde AA, Horie M, et al. HRS/EHRA/APHRS expert consensus statement on the diagnosis and management of patients with inherited primary arrhythmia syndromes: document endorsed by HRS, EHRA, and APHRS in May 2013 and by ACCF, AHA, PACES, and AEPC in June 2013. Heart Rhythm 2013; 10: 1932-1963.
2. Earle N, Crawford J, Smith W, et al. Community detection of long QT syndrome with a clinical registry: an alternative to ECG screening programs? Heart Rhythm 2013; 10: 233-238.
3. MacCormick JM, McAlister H, Crawford J, et al. Misdiagnosis of long QT syndrome as epilepsy at first presentation. Ann Emerg Med 2009; 54: 26-32.
4. Viskin S, Rosovski U, Sands AJ, et al. Inaccurate electrocardiographic interpretation of long QT: the majority of physicians cannot recognize a long QT when they see one. Heart Rhythm 2005; 2: 569-574.
5. Wenzel-Seifert K, Wittmann M, Haen E. QTc prolongation by psychotropic drugs and the risk of Torsade de Pointes. Dtsch Arztebl Int 2011; 108: 687-693.
6. Taggart NW, Haglund CM, Tester DJ, et al. Diagnostic miscues in congenital long-QT syndrome. Circulation 2007; 115: 2613-2620.
7. Lepeschkin E, Surawicz B. The measurement of the Q-T interval of the electrocardiogram. Circulation 1952; 6: 378-388.
8. Malik M. Beat-to-beat QT variability and cardiac autonomic regulation. Am J Physiol Heart Circ Physiol 2008; 295: H923-H925.
9. Anderson ME, Al-Khatib SM, Roden DM, et al. Cardiac repolarization: current knowledge, critical gaps, and new approaches to drug development and patient management. Am Heart J 2002; 144: 769-781.
10. Hofman N, Wilde AA, Kaab S, et al. Diagnostic criteria for congenital long QT syndrome in the era of molecular genetics: do we need a scoring system? Eur Heart J 2007; 28: 575-580.
11. Hobbs JB, Peterson DR, Moss AJ, et al. Risk of aborted cardiac arrest or sudden cardiac death during adolescence in the long-QT syndrome. JAMA 2006; 296: 1249-1254.
12. Morganroth J, Brozovich FV, McDonald JT, et al. Variability of the QT measurement in healthy men, with implications for selection of an abnormal QT value to predict drug toxicity and proarrhythmia. Am J Cardiol 1991; 67: 774-776.
13. Tutar HE, Ocal B, Imamoglu A, et al. Dispersion of QT and QTc interval in healthy children, and effects of sinus arrhythmia on QT dispersion. Heart 1998; 80: 77-79.
14. Postema PG, Wilde AA. The measurement of the QT interval. Curr Cardiol Rev 2014; 10: 287-294.
15. Malik M. Errors and misconceptions in ECG measurement used for the detection of drug induced QT interval prolongation. J Electrocardiol 2004; 37 Suppl: 25-33.
16. Talbot S. QT interval in right and left bundle-branch block. Br Heart J 1973; 35: 288-291.
17. Drezner JA, Ackerman MJ, Cannon BC, et al. Abnormal electrocardiographic findings in athletes: recognising changes suggestive of primary electrical disease. Br J Sports Med 2013; 47: 153-167.
18. Funck-Brentano C, Jaillon P. Rate-corrected QT interval: techniques and limitations. Am J Cardiol 1993; 72: 17B-22B.
19. Berger WR, Gow RM, Kamberi S, et al. The QT and corrected QT interval in recovery after exercise in children. Circ Arrhythm Electrophysiol 2011; 4(4): 448-455.
20. Drew BJ, Califf RM, Funk M, et al. Practice standards for electrocardiographic monitoring in hospital settings: an American Heart Association scientific statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical-Care Nurses. Circulation 2004; 110: 2721-2746.
21. Moss AJ. Measurement of the QT interval and the risk associated with QTc interval prolongation: A review. Am J Cardiol 1993; 72: 23B-25B.
22. Waddell-Smith KE, Skinner JR; members of the CSANZ Genetics Council Writing Group. Update on the diagnosis and management of familial long QT syndrome. Heart Lung Circ 2016; 25: 769-776.
23. Zhang L, Timothy KW, Vincent GM, et al. Spectrum of ST-T-wave patterns and repolarization parameters in congenital long-QT syndrome: ECG findings identify genotypes. Circulation 2000; 102: 2849-2855.
24. Monnig G, Eckardt L, Wedekind H, et al. Electrocardiographic risk stratification in families with congenital long QT syndrome. Eur Heart J 2006; 27: 2074-2080.
25. Postema PG, De Jong JS, Van der Bilt IA, et al. Accurate electrocardiographic assessment of the QT interval: teach the tangent. Heart Rhythm 2008; 5: 1015-1018.
26. Rautaharju PM, Surawicz B, Gettes LS, et al. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part IV: the ST segment, T and U waves, and the QT interval: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized Electrocardiology. J Am Coll Cardiol 2009; 53: 982-991.
27. Goldenberg I, Moss AJ, Zareba W. QT interval: how to measure it and what is “normal”. J Cardiovasc Electrophysiol 2006; 17: 333-336.
28. Viskin S, Postema PG, Bhuiyan ZA, et al. The response of the QT interval to the brief tachycardia provoked by standing: a bedside test for diagnosing long QT syndrome. J Am Coll Cardiol 2010; 55: 1955-1961.
29. Sy RW, van der Werf C, Chattha IS, et al. Derivation and validation of a simple exercise-based algorithm for prediction of genetic testing in relatives of LQTS probands. Circulation 2011; 124: 2187-2194.
30. Schwartz PJ, Crotti L. QTc behavior during exercise and genetic testing for the long-QT syndrome. Circulation 2011; 124: 2181-2184.
31. Aziz PF, Wieand TS, Ganley J, et al. Genotype- and mutation site-specific QT adaptation during exercise, recovery, and postural changes in children with long-QT syndrome. Circ Arrhythm Electrophysiol 2011; 4: 867-873.
32. Kaufman ES, Priori SG, Napolitano C, et al. Electrocardiographic prediction of abnormal genotype in congenital long QT syndrome: experience in 101 related family members. J Cardiovasc Electrophysiol 2001; 12: 455-461.
33. Mauriello DA, Johnson JN, Ackerman MJ. Holter monitoring in the evaluation of congenital long QT syndrome. Pacing Clin Electrophysiol 2011; 34: 1100-1104.
34. Vaglio M, Couderc JP, McNitt S, et al. A quantitative assessment of T-wave morphology in LQT1, LQT2, and healthy individuals based on Holter recording technology. Heart Rhythm 2008; 5: 11-18.
35. Page A, Aktas MK, Soyata T, et al. “QT clock” to improve detection of QT prolongation in long QT syndrome patients. Heart Rhythm 2016; 13: 190-198.
36. Bazett H. An analysis of the time relations of electrocardiograms. Heart 1920; 7: 353-370.
37. Milne JR, Ward DE, Spurrell RA, et al. The ventricular paced QT interval–the effects of rate and exercise. Pacing Clin Electrophysiol 1982; 5: 352-358.
38. Rijnbeek PR, van Herpen G, Bots ML, et al. Normal values of the electrocardiogram for ages 16-90 years. J Electrocardiol 2014; 47: 914-921.
39. Barsheshet A, Peterson DR, Moss AJ, et al. Genotype-specific QT correction for heart rate and the risk of life-threatening cardiac events in adolescents with congenital long-QT syndrome. Heart Rhythm 2011; 8: 1207-1213.
40. Vincent GM, Timothy KW, Leppert M, et al. The spectrum of symptoms and QT intervals in carriers of the gene for the long-QT syndrome. N Engl J Med 1992; 327: 846-852.

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Perspectives

Performance data and informed consent: a duty to disclose?

Rebekah E McWhirter

Med J Aust 2017; 207 (3): . || doi: 10.5694/mja16.01195
Published online: 7 August 2017

ARTICLE
AUTHORS
REFERENCES

Topics

Information science

Ethics and law

Evidence mounts for a legal duty to disclose performance data as part of informed consent

Hospitals, colleges and other institutions increasingly collect, analyse and disseminate data relating to the performance of individual health practitioners, particularly those undertaking surgical procedures. Arguments have long been made for an ethical duty to disclose information regarding a practitioner’s experience or skill to patients as part of the process of informed consent (Box 1).1 Significantly, recent developments suggest that practitioners may, in some circumstances, have a legal duty to disclose their performance data to patients (Box 2).

Menzies Institute for Medical Research and Centre for Law and Genetics, University of Tasmania, Hobart, TAS

Correspondence: Rebekah.McWhirter@utas.edu.au

Acknowledgements:

I am grateful to Bill Madden for his comments on earlier drafts of this article.

Competing interests:

No relevant disclosures.

1. Clarke S, Oakley J. Informed consent and surgeons’ performance. J Med Philos 2004; 29: 11-35.
2. Chappel v Hart (1998) 195 CLR 232.
3. Brus v Australian Capital Territory [2007] ACTSC 83.
4. G & C v Down [2008] SADC 135.
5. Morocz v Marshman [2015] NSWSC 325.
6. Civil Law (Wrongs) Act 2002 (ACT); Civil Liability Act 2002 (NSW); Personal Injuries (Liabilities and Damages) Act 2003 (NT); Civil Liability Act 2003 (Qld); Civil Liability Act 1936 (SA); Civil Liability Act 2002 (Tas); Wrongs Act 1958 (Vic); Civil Liability Act 2002 (WA).
7. Ipp DA, Cane P, Sheldon D, Macintosh I. Review of the law of negligence: final report. Canberra: Commonwealth of Australia, 2002.
8. Rogers v Whitaker (1992) 175 CLR 479.
9. F v R (1983) 33 SASR 189.
10. Rosenberg v Percival (2001) 205 CLR 434.
11. Brown DL, Clarke S, Oakley J. Cardiac surgeon report cards, referral for cardiac surgery, and the ethical responsibilities of cardiologists. J Am Coll Cardiol 2012; 59: 2378-2382.
12. Radford PD, Derbyshire LF, Shalhoub J, Fitzgerald JEF. Publication of surgeon specific outcome data: a review of implementation, controversies and the potential impact on surgical training. Int J Surg 2015; 13: 211-216.
13. Royal Australasian College of Surgeons. Australian and New Zealand audit of surgical mortality: national report 2014. Adelaide: RACS, 2014. http://www.surgeons.org/media/22243780/2015-11-23_rpt_anzasm_report_2014.pdf (accessed June 2017).
14. Medical Board of Australia. Guidelines for registered medical practitioners who perform cosmetic medical and surgical procedures. 1 October 2016. http://www.medicalboard.gov.au/News/2016-05-09-media-statement.aspx (accessed June 2017).

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Perspectives

Specialist outreach services in regional and remote Australia: key drivers and policy implications

Belinda G O'Sullivan, Johannes U Stoelwinder and Matthew R McGrail

Med J Aust 2017; 207 (3): . || doi: 10.5694/mja16.00949
Published online: 7 August 2017

ARTICLE
AUTHORS
REFERENCES

Topics

Health services administration

Promoting the supply, distribution and sustainability of rural outreach services requires multilevel policy development and regional service planning

The need for more local specialist services to support rural communities is well established as a significant issue in Australia. Although the specialist workforce is growing, providers are increasingly choosing to subspecialise and work in metropolitan practice.1 Access to medical specialists in major cities is consistently high at 162.1 full-time equivalent specialists per 100 000 population, but diminishes for people living in inner or outer regional (82.7 and 61.5 per 100 000 respectively) and remote areas (34.2 per 100 000).2

1 School of Rural Health, Monash University, Bendigo, VIC
2 School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC

Correspondence: belinda.osullivan@monash.edu

Acknowledgements:

This publication used data from the MABEL longitudinal survey of doctors conducted by the University of Melbourne and Monash University (the MABEL research team). Funding for MABEL comes from the National Health and Medical Research Council (Health Services Research grant, 2008–2011; Centre for Research Excellence in Medical Workforce Dynamics, 2012–2016) with additional support from the Department of Health (2008) and Health Workforce Australia (2013). Belinda O’Sullivan was supported by a Postgraduate Publications Award from Monash University.

Competing interests:

No relevant disclosures.

1. Health Workforce Australia. Health workforce 2025. Vol 3: medical specialties. Adelaide: Health Workforce Australia, 2012. http://pandora.nla.gov.au/pan/133228/20150419-0017/www.hwa.gov.au/sites/uploads/HW2025_V3_FinalReport20121109.pdf (accessed Nov 2016).
2. Australian Institute of Health and Welfare (AIHW). Medical Workforce 2015. Canberra: AIHW, 2016. http://www.aihw.gov.au/workforce/medical/additional (accessed Nov 2016).
3. de Roodenbeke E, Lucas S, Rouzaut A, Bana F. Outreach services as a strategy to increase access to health workers in remote and rural areas. (Technical Report No. 2). Geneva: World Health Organization, 2011. http://whqlibdoc.who.int/publications/2011/9789241501514_eng.pdf (accessed Nov 2016).
4. Simm PJ, Wong N, Fraser L, et al. Geography does not limit optimal diabetes care: use of a tertiary centre model of care in an outreach service for type 1 diabetes mellitus. J Paediatr Child Health 2014; 50: 471-475.
5. Gruen RL, Bailie RS, Wang Z, et al. Specialist outreach to isolated and disadvantaged communities: a population-based study. Lancet 2006; 368: 130-138.
6. Thomas CL, O’Rourke PK, Wainwright CE. Clinical outcomes of Queensland children with cystic fibrosis: a comparison between tertiary centre and outreach services. Med J Aust 2008; 188: 135-139. <MJA full text>
7. Medlin LG, Chang AB, Fong K, et al. Indigenous Respiratory Outreach Care: The first 18 months of a specialist respiratory outreach service to rural and remote Indigenous communities in Queensland, Australia. Aust Health Rev 2014; 38: 447-453.
8. Ojo EO, Okoi E, Umoiyoho AJ, Nnamonu M. Surgical outreach program in poor rural Nigerian communities. Rural Remote Health 2013; 13: 2200.
9. Finger RP, Kupitz DG, Holz FG, et al. Regular provision of outreach increases acceptance of cataract surgery in South India. Trop Med Int Health 2011; 16: 1268-1275.
10. O’Sullivan BG, Joyce CM, McGrail MR. Adoption, implementation and prioritization of specialist outreach policy in Australia: a national perspective. Bull World Health Organ 2014; 92: 512-519.
11. O’Sullivan B, Joyce C, McGrail M. Rural outreach by specialist doctors in Australia: a national cross-sectional study of supply and distribution. Hum Resour Health 2014; 12: 1-10.
12. O'Sullivan BG, McGrail MR, Stoelwinder JU. Reasons why specialist doctors undertake rural outreach services: an Australian cross-sectional study. Hum Resour Health 2017; 15: 1-7.
13. O’Sullivan B, McGrail M, Joyce C, Stoelwinder J. Service distribution and models of rural outreach by specialist doctors in Australia: a national cross-sectional study. Aust Health Rev 2016; 40: 330-336.
14. O’Sullivan B, Stoelwinder J, McGrail M. The stability of rural outreach services: a national longitudinal study of specialist doctors. Med J Aust 2015; 203: 297. <MJA full text>
15. O'Sullivan B. Rural outreach by specialist doctors in Australia [PhD thesis]. Melbourne: Monash University, 2016. http://arrow.monash.edu.au/hdl/1959.1/1268685 (accessed June 2017).
16. O’Sullivan B, McGrail M, Stoelwinder J. Subsidies to target specialist outreach services into more remote locations: a national cross-sectional study. Aust Health Rev 2017; 41: 344-350.
17. Turner AW, Mulholland WJ, Taylor HR. Coordination of outreach eye services in remote Australia. Clin Exp Ophthalmol 2011; 39: 344-349.

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Research

The Australian Snakebite Project, 2005–2015 (ASP-20)

Christopher I Johnston, Nicole M Ryan, Colin B Page, Nicholas A Buckley, Simon GA Brown, Margaret A O'Leary and Geoffrey K Isbister

Med J Aust 2017; 207 (3): . || doi: 10.5694/mja17.00094
Published online: 31 July 2017

ARTICLE
AUTHORS
REFERENCES

Topics

Wounds and injuries

Poisoning

Emergency medicine

Abstract

Objective: To describe the epidemiology, treatment and adverse events after snakebite in Australia.

Design: Prospective, multicentre study of data on patients with snakebites recruited to the Australian Snakebite Project (2005–2015) and data from the National Coronial Information System.

Setting, participants: Patients presenting to Australian hospitals with suspected or confirmed snakebites from July 2005 to June 2015 and consenting to participation.

Main outcome measures: Demographic data, circumstances of bites, clinical effects of envenoming, results of laboratory investigations and snake venom detection kit (SVDK) testing, antivenom treatment and adverse reactions, time to discharge, deaths.

Results: 1548 patients with suspected snakebites were enrolled, including 835 envenomed patients (median, 87 per year), for 718 of which the snake type was definitively established, most frequently brown snakes (41%), tiger snakes (17%) and red-bellied black snakes (16%). Clinical effects included venom-induced consumption coagulopathy (73%), myotoxicity (17%), and acute kidney injury (12%); severe complications included cardiac arrest (25 cases; 2.9%) and major haemorrhage (13 cases; 1.6%). There were 23 deaths (median, two per year), attributed to brown (17), tiger (four) and unknown (two) snakes; ten followed out-of-hospital cardiac arrests and six followed intracranial haemorrhages. Of 597 SVDK test results for envenomed patients with confirmed snake type, 29 (4.9%) were incorrect; 133 of 364 SVDK test results for non-envenomed patients (36%) were false positives. 755 patients received antivenom, including 49 non-envenomed patients; 178 (24%), including ten non-envenomed patients, had systemic hypersensitivity reactions, of which 45 (6%) were severe (hypotension, hypoxaemia). Median total antivenom dose declined from four vials to one, but median time to first antivenom was unchanged (4.3 hours; IQR, 2.7–6.3 hours).

Conclusions: Snake envenoming is uncommon in Australia, but is often severe. SVDKs were unreliable for determining snake type. The median antivenom dose has declined without harming patients. Improved early diagnostic strategies are needed to reduce the frequently long delays before antivenom administration.

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1 NSW Poisons Information Centre, Sydney Children's Hospitals Network, Sydney, NSW
2 University of Newcastle, Newcastle, NSW
3 Calvary Mater Newcastle, Newcastle, NSW
4 University of Sydney, Sydney, NSW
5 University of Western Australia, Perth, WA
6 Centre for Clinical Research in Emergency Medicine (CCREM), Harry Perkins Institute of Medical Research, Perth, WA

Correspondence: geoff.isbister@gmail.com

Acknowledgements:

Geoffrey Isbister is supported by a National Health and Medical Research Council (NHMRC) Senior Research Fellowship (1061041). Nicole Ryan is supported by an NHMRC Early Career Fellowship. Colin Page is funded by a Queensland Emergency Medicine Research Foundation Fellowship. The study described in this article is funded by an NHMRC Centre for Research Excellence Grant (1110343). We acknowledge the help of numerous critical care nurses and medical staff who assisted in recruiting patients to the study, and the local investigators at hospitals around Australia.

Competing interests:

Christopher Johnston is employed by Boehringer Ingelheim; this research was independent of his employment by Boehringer Ingelheim.

1. Sutherland SK, Tibballs J. Australian animal toxins: the creatures, their toxins and care of the poisoned patient. 2nd edition. Melbourne: Oxford University Press, 2001.
2. Sutherland SK. Deaths from snake bite in Australia, 1981–1991. Med J Aust 1992; 157: 740-746.
3. Sutherland SK, Leonard RL. Snakebite deaths in Australia 1992–1994 and a management update. Med J Aust 1995; 163: 616-618.
4. Winkel KD, Mirtschin P, Pearn J. Twentieth century toxinology and antivenom development in Australia. Toxicon 2006; 48: 738-754.
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6. Munro JG, Pearn JH. Snake bite in children: a five year population study from South-East Queensland. Aust Paediatr J 1978; 14: 248-253.
7. Jamieson R, Pearn J. An epidemiological and clinical study of snake-bites in childhood. Med J Aust 1989; 150: 698-702.
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14. Yeung JM, Little M, Murray LM, et al. Antivenom dosing in 35 patients with severe brown snake (Pseudonaja) envenoming in Western Australia over 10 years. Med J Aust 2004; 181: 703-705. <MJA full text>
15. de Silva HA, Ryan NM, de Silva HJ. Adverse reactions to snake antivenom, and their prevention and treatment. Br J Clin Pharmacol 2016; 81: 446-452.
16. Currie BJ. Treatment of snakebite in Australia: the current evidence base and questions requiring collaborative multicentre prospective studies. Toxicon 2006; 48: 941-956.
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18. Johnston CI, Ryan NM, O’Leary MA, et al. Australian taipan (Oxyuranus spp.) envenoming: clinical effects and potential benefits of early antivenom therapy — Australian Snakebite Project (ASP-25). Clin Toxicol (Phila) 2017; 55: 115-122.
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20. Sampson HA, Muñoz-Furlong A, Campbell RL, et al. Second symposium on the definition and management of anaphylaxis: summary report — Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol 2006; 117: 391-397.
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22. Bugeja L, Ibrahim JE, Ferrah N, et al. The utility of medico-legal databases for public health research: a systematic review of peer-reviewed publications using the National Coronial Information System. Health Res Policy Syst 2016; 14: 28.
23. Johnston CI, O’Leary MA, Brown SG, et al. Death adder envenoming causes neurotoxicity not reversed by antivenom — Australian Snakebite Project (ASP-16). PLoS Negl Trop Dis 2012; 6: e1841.
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25. Johnston CI, Brown SG, O’Leary MA, et al. Mulga snake (Pseudechis australis) envenoming: a spectrum of myotoxicity, anticoagulant coagulopathy, haemolysis and the role of early antivenom therapy — Australian Snakebite Project (ASP-19). Clin Toxicol (Phila) 2013; 51: 417-424.
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27. Allen GE, Brown SG, Buckley NA, et al. Clinical effects and antivenom dosing in brown snake (Pseudonaja spp.) envenoming — Australian snakebite project (ASP-14). PLoS One 2012; 7: e53188.
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Research

Assisted reproductive technology in Australia and New Zealand: cumulative live birth rates as measures of success

Georgina M Chambers, Repon C Paul, Katie Harris, Oisin Fitzgerald, Clare V Boothroyd, Luk Rombauts, Michael G Chapman and Louisa Jorm

Med J Aust 2017; 207 (3): . || doi: 10.5694/mja16.01435
Published online: 24 July 2017

ARTICLE
AUTHORS
REFERENCES

Topics

Women's health

Abstract

Objectives: To estimate cumulative live birth rates (CLBRs) following repeated assisted reproductive technology (ART) ovarian stimulation cycles, including all fresh and frozen/thaw embryo transfers (complete cycles).

Design, setting and participants: Prospective follow-up of 56 652 women commencing ART in Australian and New Zealand during 2009–2012, and followed until 2014 or the first treatment-dependent live birth.

Main outcome measures: CLBRs and cycle-specific live birth rates were calculated for up to eight cycles, stratified by the age of the women (< 30, 30–34, 35–39, 40–44, > 44 years). Conservative CLBRs assumed that women discontinuing treatment had no chance of achieving a live birth if had they continued treatment; optimal CLBRs assumed that they would have had the same chance as women who continued treatment.

Results: The overall CLBR was 32.7% (95% CI, 32.2–33.1%) in the first cycle, rising by the eighth cycle to 54.3% (95% CI, 53.9–54.7%) (conservative) and 77.2% (95% CI, 76.5–77.9%) (optimal). The CLBR decreased with age and number of complete cycles. For women who commenced ART treatment before 30 years of age, the CLBR for the first complete cycle was 43.7% (95% CI, 42.6–44.7%), rising to 69.2% (95% CI, 68.2–70.1%) (conservative) and 92.8% (95% CI, 91.6–94.0) (optimal) for the seventh cycle. For women aged 40–44 years, the CLBR was 10.7% (95% CI, 10.1–11.3%) for the first complete cycle, rising to 21.0% (95% CI, 20.2–21.8%) (conservative) and 37.9% (95% CI, 35.9–39.9%) (optimal) for the eighth cycle.

Conclusion: CLBRs based on complete cycles are meaningful estimates of ART success, reflecting contemporary clinical practice and encouraging safe practice. These estimates can be used when counselling patients and to inform public policy on ART treatment.

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1 National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health and School of Women's and Children's Health, University of New South Wales, Sydney, NSW
2 Care Fertility, Brisbane, QLD
3 Monash IVF, Melbourne, VIC
4 IVF Australia Southern Sydney, Sydney, NSW
5 Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW

Correspondence: g.chambers@unsw.edu.au

Acknowledgements:

The Fertility Society of Australia funds the Australian and New Zealand Assisted Reproductive Database (ANZARD). We acknowledge the provision of data to ANZARD by Australian and New Zealand fertility clinics.

Competing interests:

The Fertility Society of Australia funds the National Perinatal Epidemiology and Statistics Unit to manage ANZARD and conduct national reporting of ART in Australia and New Zealand. Georgina Chambers is employed by the University of New South Wales (UNSW) and is director of the National Perinatal Epidemiology and Statistics Unit at UNSW. She has received an institutional research grant unrelated to this study from the Australian Research Council for which Virtus Health, a publicly listed IVF company, was the partner organisation (2010–2013). Clare Boothroyd owns a facility that offers ART, and has received funding from MSD, Merck-Serono, and Ferring for work unrelated to this article. Luk Rombauts has a minority shareholding in the Monash IVF Group, a publicly listed IVF company, and has received funding from MSD, Merck-Serono, and Ferring for work unrelated to this article. Michael Chapman has a minority shareholding in Virtus Health, and has received funding from MSD, Merck-Serono, and Ferring for work unrelated to this article.

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Narrative review

Iron deficiency and new insights into therapy

Michael SY Low and George Grigoriadis

Med J Aust 2017; 207 (2): . || doi: 10.5694/mja16.01304
Published online: 17 July 2017

ARTICLE
AUTHORS
REFERENCES

Topics

Hematologic diseases

Summary

Iron deficiency and iron deficiency anaemia remain prevalent in Australia.
The groups at highest risk are pre-menopausal women, socially disadvantaged people and those of Indigenous background.
Diagnosing iron deficiency using a full blood examination and iron studies can be difficult and can be further complicated by concomitant inflammation. Results of iron studies should always be interpreted as an overall picture rather than focusing on individual parameters. In difficult clinical scenarios, soluble transferrin receptor assays can be useful.
Management of iron deficiency involves identification and treatment of the cause of iron deficiency, as well as effective iron replacement.
Clinicians should always take a detailed history and perform a comprehensive physical examination of a patient with iron deficiency. Patients should be monitored even if a likely cause of iron deficiency is identified.
Patients who fail to respond to iron replacement or maintain iron status should be referred for further investigation, including endoscopy to exclude internal bleeding.
Both enteral and parenteral iron are effective at replacing iron. For most adult patients, we recommend trialling daily oral iron (30–100 mg of elemental iron) as the first-line therapy.
Safety and efficacy of intravenous iron infusions have improved with the availability of a newer formulation, ferric carboxymaltose. Patients who fail to respond to oral iron replacement can be safely managed with intravenous iron.
Blood transfusion for iron deficiency anaemia should be reserved for life-threatening situations and should always be followed by appropriate iron replacement.

1 Monash Health, Melbourne, VIC
2 Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC
3 Monash University, Melbourne, VIC

Correspondence: george.grigoriadis@monash.edu

Acknowledgements:

Michael Low is employed by Monash Health and funded by a Royal Australasian College of Physicians (RACP) National Health and Medical Research Council (NHMRC) CRB Blackburn Scholarship. George Grigoriadis is employed by Monash Health and Alfred Health and funded by a Victorian Cancer Agency Clinical Research Fellowship. We thank Shahla Vilcassim (Monash Haematology) for her help in attaining the figure in .

Competing interests:

No relevant disclosures.

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Research

High rates of general practice attendance by former prisoners: a prospective cohort study

Megan Carroll, Matthew J Spittal, Anna R Kemp-Casey, Nicholas G Lennox, David B Preen, Georgina Sutherland and Stuart A Kinner

Med J Aust 2017; 207 (2): . || doi: 10.5694/mja16.00841
Published online: 17 July 2017

ARTICLE
AUTHORS
REFERENCES

Topics

Social determinants of health

General medicine

Health services administration

Abstract

Objectives: To determine the rates at which people recently released from prison attend general practitioners, and to describe service users and their encounters.

Design, participants and setting: Prospective cohort study of 1190 prisoners in Queensland, interviewed up to 6 weeks before expected release from custody (August 2008 – July 2010); their responses were linked prospectively with Medicare and Pharmaceutical Benefits Scheme data for the 2 years after their release. General practice attendance was compared with that of members of the general Queensland population of the same sex and in the same age groups.

Main outcome measures: Rates of general practice attendance by former prisoners during the 2 years following their release from prison.

Results: In the 2 years following release from custody, former prisoners attended general practice services twice as frequently (standardised rate ratio, 2.04; 95% CI, 2.00–2.07) as other Queenslanders; 87% of participants visited a GP at least once during this time. 42% of encounters resulted in a filled prescription, and 12% in diagnostic testing. Factors associated with higher rates of general practice attendance included history of risky opiate use (incidence rate ratio [IRR], 2.09; 95% CI, 1.65–2.65), having ever been diagnosed with a mental disorder (IRR, 1.32; 95% CI, 1.14–1.53), and receiving medication while in prison (IRR, 1.82; 95% CI, 1.58–2.10).

Conclusions: Former prisoners visited general practice services with greater frequency than the general Queensland population. This is consistent with their complex health needs, and suggests that increasing access to primary care to improve the health of former prisoners may be insufficient, and should be accompanied by improving the quality, continuity, and cultural appropriateness of care.

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1 Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC
2 Centre for Health Services Research, University of Western Australia, Perth, WA
3 Quality Use of Medicines Pharmacy Research Centre, University of South Australia, Adelaide, SA
4 Queensland Centre for Intellectual and Developmental Disability, Brisbane, QLD
5 University of Western Australia, Perth, WA
6 Griffith Criminology Institute, Griffith University, Brisbane, QLD
7 Menzies Health Institute Queensland, Griffith University, Brisbane, QLD

Correspondence: m.carroll@student.unimelb.edu.au

Acknowledgements:

We thank Queensland Corrective Services for assistance with data collection, and Passports study participants for sharing their stories. We acknowledge the Australian Government Department of Human Services as the source of Medicare and Pharmaceutical Benefits Scheme (PBS) records. The Passports study was funded by a National Health and Medical Research Council (NHMRC) Strategic Award (409966). The HIP-Aus study is funded by a National Health and Medical Research Council Project grant (1002463). Stuart Kinner is supported by an NHMRC Senior Research Fellowship (APP1078168). The views expressed in this article are solely those of the authors, and in no way reflect the views or policies of Queensland Corrective Services.

Competing interests:

No relevant disclosures.

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Assisted reproductive technologies: new guidance for women and doctors is welcome

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How to measure a QT interval

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Performance data and informed consent: a duty to disclose?

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Specialist outreach services in regional and remote Australia: key drivers and policy implications

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The Australian Snakebite Project, 2005–2015 (ASP-20)

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Assisted reproductive technology in Australia and New Zealand: cumulative live birth rates as measures of success

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Iron deficiency and new insights into therapy

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High rates of general practice attendance by former prisoners: a prospective cohort study

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Changes in pathology test ordering by early career general practitioners: a longitudinal study

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Can antibiotic prescribing for respiratory infections be reduced?

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Pagination