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    Implementing change: evaluating the Accelerated Chest pain Risk Evaluation (ACRE) project

    William A Parsonage, Tanya Milburn, Sarah Ashover, Wade Skoien, Jaimi H Greenslade, Louise McCormack and Louise Cullen
    Med J Aust 2017; 207 (5): . || doi: 10.5694/mja16.01479
    Published online: 4 September 2017

    Abstract

    Objective: To evaluate hospital length of stay (LOS) and admission rates before and after implementation of an evidence-based, accelerated diagnostic protocol (ADP) for patients presenting to emergency departments (EDs) with chest pain.

    Design: Quasi-experimental design, with interrupted time series analysis for the period October 2013 – November 2015.

    Setting, participants: Adults presenting with chest pain to EDs of 16 public hospitals in Queensland.

    Intervention: Implementation of the ADP by structured clinical re-design.

    Main outcome measures: Primary outcome: hospital LOS. Secondary outcomes: ED LOS, hospital admission rate, proportion of patients identified as being at low risk of an acute coronary syndrome (ACS).

    Results: Outcomes were recorded for 30 769 patients presenting before and 23 699 presenting after implementation of the ADP. Following implementation, 21.3% of patients were identified by the ADP as being at low risk for an ACS. Following implementation of the ADP, mean hospital LOS fell from 57.7 to 47.3 hours (rate ratio [RR], 0.82; 95% CI, 0.74–0.91) and mean ED LOS for all patients presenting with chest pain fell from 292 to 256 minutes (RR, 0.80; 95% CI, 0.72–0.89). The hospital admission rate fell from 68.3% (95% CI, 59.3–78.5%) to 54.9% (95% CI, 44.7–67.6%; P < 0.01). The estimated release in financial capacity amounted to $2.3 million as the result of reduced ED LOS and $11.2 million through fewer hospital admissions.

    Conclusions: Implementing an evidence-based ADP for assessing patients with chest pain was feasible across a range of hospital types, and achieved a substantial release of health service capacity through reductions in hospital admissions and ED LOS.

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    • 1 Royal Brisbane and Women's Hospital, Brisbane, QLD
    • 2 Queensland University of Technology, Brisbane, QLD
    • 3 The University of Queensland, Brisbane, QLD


    Correspondence: w.parsonage@mac.com
    Acknowledgements: 

    The ACRE Project was funded by the Queensland Government Department of Health. We acknowledge the support of the Healthcare Improvement Unit, Queensland Department of Health. We thank the Queensland Research Linkage Group of the Department of Health for assistance with linking data from the emergency department and inpatient datasets. We also gratefully acknowledge the contributions of former project officers Jennifer Bilesky, Jo Sippel and Vandana Bettens in the early development of the project, and the staff of the participating hospitals.

    Competing interests:

    No relevant disclosures.

    • 1. Australian Institute of Health and Welfare. Emergency department care 2015–16: Australian hospital statistics (AIHW Cat. No. HSE 182; Health Services Series No. 72). Canberra: AIHW, 2016.
    • 2. Cullen L, Greenslade J, Hammett CJ, et al. Comparison of three risk stratification rules for predicting patients with acute coronary syndrome presenting to an Australian emergency department. Heart Lung Circ 2013; 22: 844-851.
    • 3. Aroney CN, Aylward P, Kelly A, et al. Guidelines for the management of acute coronary syndromes. Med J Aust 2006; 184 (8 Suppl): S1-S29. <MJA full text>
    • 4. Cullen L, Greenslade J, Merollini K, et al. Cost and outcomes of assessing patients with chest pain in an Australian emergency department. Med J Aust 2015; 202: 427-432. <MJA full text>
    • 5. Than M, Cullen L, Aldous S, et al. A 2-hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker (ADAPT). J Am Coll Cardiol 2012; 59: 2091-2098.
    • 6. George T, Ashover S, Cullen L, et al. Introduction of an accelerated diagnostic protocol in the assessment of emergency department patients with possible acute coronary syndrome: the Nambour Short Low-Intermediate Chest pain project. Emerg Med Australas 2013; 25: 340-344.
    • 7. Mahler SA, Miller CD, Litt HI, et al. Performance of the 2-hour accelerated diagnostic protocol within the American College of Radiology Imaging Network PA 4005 cohort. Acad Emerg Med 2015; 22: 452-460.
    • 8. Than M, Pickering J, Aldous S, et al. Effectiveness of EDACS versus ADAPT accelerated diagnostic pathways for chest pain: a pragmatic randomized controlled trial embedded within practice. Ann Emerg Med 2016; 68: 93-102.
    • 9. Skoien W, Page K, Parsonage W, et al. Use of the theoretical domains framework to evaluate factors driving successful implementation of the Accelerated Chest pain Risk Evaluation (ACRE) project. Implement Sci 2016; 11: 136.
    • 10. Mahler SA, Riley RF, Hiestand BC, et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes 2015; 8: 195-203.
    • 11. Mahler SA, Miller CD, Litt HI, et al. Performance of the 2-hour Accelerated Diagnostic Protocol within the American College of Radiology Imaging Network PA 4005 cohort. Acad Emerg Med 2015; 22: 452-460.
    • 12. Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med 2011; 104: 510-520.
    • 13. 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>
    • 14. Fanaroff AC, Schulteis RD, Pieper KS, et al. Simplified predictive instrument to rule out acute coronary syndromes in a high-risk population. J Am Heart Assoc 2015; 4: e002351.
    • 15. Roffi M, Patrono C, Collet JP, et al. Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2016; 37: 267-315.

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      Statistical and clinical significance

      Ian A Scott
      Med J Aust 2017; 207 (5): . || doi: 10.5694/mja16.01148
      Published online: 4 September 2017

      In published research, a statistically significant result is often wrongly interpreted as representing a clinically important finding. In this article, we explore the meanings of statistical and clinical significance.


      • 1 Princess Alexandra Hospital, Brisbane, QLD
      • 2 University of Queensland, Brisbane, QLD


      Correspondence: ian.scott@health.qld.gov.au
      Competing interests:

      No relevant disclosures.

      • 1. Jones MP, Beath A, Oldmeadow C, Attia JR. Understanding statistical hypothesis tests and power. Med J Aust 2017; 207: 148-150. <MJA full text>
      • 2. Akobeng AK. Understanding type I and type II errors, statistical power and sample size. Acta Paediatr 2016; 105: 605-609.
      • 3. Furukawa TA, Scott IA, Guyatt G. Chapter 12.5: Measuring patients’ experience. In: Guyatt G, Rennie D, Meade MO, Cook DJ, editors. Users’ guides to the medical literature. A manual for evidence-based practice. 3rd ed. Boston: JAMA Press, 2015: pp. 219-234.
      • 4. Pocock SJ, Ware JH. Translating statistical findings into plain English. Lancet 2009; 373: 1926-1928.
      • 5. Gardner MJ, Altman DG. Confidence intervals rather than P values: estimation rather than hypothesis testing. BMJ 1986; 292: 746-750.
      • 6. Pocock SJ, Stone GW. The primary outcome is positive – is that good enough? N Engl J Med 2016; 375: 971-979.
      • 7. Pocock J, Stone GW. The primary outcome fails – what next? N Engl J Med 2016; 375: 861-870.
      • 8. Montori VM, Devereaux PJ, Adhikari NK, et al. Randomized trials stopped early for benefit: a systematic review. JAMA 2005; 294: 2203-2209.
      • 9. Mulla SM, Scott IA, Jackevicius CA, et al. User’s guide to the medical literature. How to use a non-inferiority trial. JAMA 2012; 308: 2605-2611.
      • 10. Seruga B, Templeton AJ, Badillo FE, et al. Under-reporting of harm in clinical trials. Lancet Oncol 2016; 17: e209-e219.
      • 11. Liao JM, Stack CB, Griswold ME, Localio AR. Understanding clinical research: intention to treat analysis. Ann Intern Med 2017; 166: 662-664.

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        Improving the safety of breast implants: implant-associated lymphoma

        Ingrid Hopper, Susannah Ahern, John J McNeil, Anand K Deva, Elisabeth Elder, Colin Moore and Rodney Cooter
        Med J Aust 2017; 207 (5): . || doi: 10.5694/mja17.00005
        Published online: 28 August 2017

        A likely causal link between breast implants and lymphoma highlights the importance of a prospective registry

        Breast devices, including implants and tissue expanders, are classified as class III (high risk) medical devices by the Therapeutic Goods Administration, and are subject to the highest level of regulatory control. They have been associated with highly publicised health scares in the past, particularly, the Poly Implant Prothèse crisis.1 More recently, breast implants have again created national concern, with the Therapeutic Goods Administration confirming in late 2016 that there were 46 reports of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) in Australia, including three cases that resulted in death. This number has since increased to 53.2 Most breast implants are used in young women and in women who have had breast cancer, thus long term exposure to these devices can be anticipated. It is therefore imperative to identify serious adverse effects at the earliest opportunity. The Australian Breast Device Registry is ideally positioned to do this, but it requires sufficient resources and engagement to ensure that it remains fit for purpose.


        • 1 Monash University, Melbourne, VIC
        • 2 University of Melbourne, Melbourne, VIC
        • 3 Macquarie University, Sydney, NSW
        • 4 Integrated Specialist Healthcare, Sydney, NSW
        • 5 Westmead Breast Cancer Institute, Sydney, NSW
        • 6 Breast Surgeons of Australia and New Zealand, Sydney, NSW
        • 7 Australasian College of Cosmetic Surgery, Sydney, NSW
        • 8 Australasian Foundation for Plastic Surgery, Sydney, NSW


        Correspondence: Ingrid.Hopper@monash.edu
        Acknowledgements: 

        The Department of Health provides funding for the Australian Breast Device Registry. Ingrid Hopper is supported by a National Health and Medical Research Council early career fellowship.

        Competing interests:

        No relevant disclosures.

        • 1. Jeeves AE, Cooter RD. Transforming Australia’s Breast Implant Registry. Med J Aust 2012; 196: 232-234. <MJA full text>
        • 2. Therapeutic Goods Administration. Breast implants and anaplastic large cell lymphoma. https://www.tga.gov.au/alert/breast-implants (accessed July 2017).
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        • 11. Deva AK, Adams WP, Vickery K. The role of bacterial biofilms in device-associated infection. Plast Reconstr Surg 2013; 132: 1319-1328.
        • 12. de Steiger RN, Hang JR, Miller LN, et al. Five-year results of the ASR XL Acetabular System and the ASR Hip Resurfacing System: an analysis from the Australian Orthopaedic Association National Joint Replacement Registry. J Bone Joint Surg Am 2011; 93: 2287-2293.
        • 13. van der Veer SN, de Keizer NF, Ravelli AC, et al. Improving quality of care. A systematic review on how medical registries provide information feedback to health care providers. Int J Med Inform 2010; 79: 305-323.
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        • 15. Cooter RD, Barker S, Carroll SM, et al. International importance of robust breast device registries. Plast Reconstr Surg 2015; 135: 330-336.

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          Coeliac disease: review of diagnosis and management

          Marjorie M Walker, Jonas F Ludvigsson and David S Sanders
          Med J Aust 2017; 207 (4): . || doi: 10.5694/mja16.00788
          Published online: 21 August 2017

          Summary

           

          • Coeliac disease is an immune-mediated systemic disease triggered by exposure to gluten, and manifested by small intestinal enteropathy and gastrointestinal and extra-intestinal symptoms. Recent guidelines recommend a concerted use of clear definitions of the disease.
          • In Australia, the most recent estimated prevalence is 1.2% in adult men (1:86) and 1.9% in adult women (1:52). Active case finding is appropriate to diagnose coeliac disease in high risk groups. Diagnosis of coeliac disease is important to prevent nutritional deficiency and long term risk of gastrointestinal malignancy.
          • The diagnosis of coeliac disease depends on clinico-pathological correlation: history, presence of antitransglutaminase antibodies, and characteristic histological features on duodenal biopsy (when the patient is on a gluten-containing diet). Human leucocyte antigen class II haplotypes DQ2 or DQ8 are found in nearly all patients with coeliac disease, but are highly prevalent in the general population at large (56% in Australia) and testing can only exclude coeliac disease for individuals with non-permissive haplotypes.
          • Adhering to a gluten free diet allows duodenal mucosal healing and alleviates symptoms. Patients should be followed up with a yearly review of dietary adherence and a health check.
          • Non-coeliac gluten or wheat protein sensitivity is a syndrome characterised by both gastrointestinal and extra-intestinal symptoms related to the ingestion of gluten and possibly other wheat proteins in people who do not have coeliac disease or wheat allergy recognised by diagnostic tests.

           


          • 1 University of Newcastle, Newcastle, NSW
          • 2 Karolinksa Institutet, Stockholm, Sweden
          • 3 Royal Hallamshire Hospital, Sheffield, United Kingdom


          Competing interests:

          No relevant disclosures.

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            Opting for rural practice: the influence of medical student origin, intention and immersion experience

            Denese Playford, Hanh Ngo, Surabhi Gupta and Ian B Puddey
            Med J Aust 2017; 207 (4): . || doi: 10.5694/mja16.01322
            Published online: 21 August 2017

            Abstract

            Objective: To compare the influence of rural background, rural intent at medical school entry, and Rural Clinical School (RCS) participation on the likelihood of later participation in rural practice.

            Design: Analysis of linked data from the Medical School Outcomes Database Commencing Medical Students Questionnaire (CMSQ), routinely collected demographic information, and the Australian Health Practitioner Regulation Agency database on practice location.

            Setting and participants: University of Western Australia medical students who completed the CMSQ during 2006–2010 and were practising medicine in 2016.

            Main outcome measures: Medical practice in rural areas (ASGC-RAs 2–5) during postgraduate years 2–5.

            Results: Full data were available for 508 eligible medical graduates. Rural background (OR, 3.91; 95% CI, 2.12–7.21; P < 0.001) and experience in an RCS (OR, 1.93; 95% CI, 1.05–3.54; P = 0.034) were significant predictors of rural practice in the multivariate analysis of all potential factors. When interactions between intention, origin, and RCS experience were included, RCS participation significantly increased the likelihood of graduates with an initial rural intention practising in a rural location (OR, 3.57; 95% CI, 1.25–10.2; P = 0.017). The effect of RCS participation was not significant if there was no pre-existing intention to practise rurally (OR, 1.38; 95% CI, 0.61–3.16; P = 0.44).

            Conclusion: For students who entered medical school with the intention to later work in a rural location, RCS experience was the deciding factor for realising this intention. Background, intent and RCS participation should all be considered if medical schools are to increase the proportion of graduates working rurally.

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            • 1 The Rural Clinical School of Western Australia, University of Western Australia, Perth, WA
            • 2 University of Western Australia, Perth, WA


            Correspondence: denese.playford@uwa.edu.au
            Acknowledgements: 

            We acknowledge the statistical advice of Sharon Evans, senior biostatistician, and the support of David Atkinson, head of the Rural Clinical School of Western Australia.

            Competing interests:

            No relevant disclosures.

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            • 2. Clark T, Freedman SB, Croft AJ, et al. Medical graduates becoming rural doctors: rural background versus extended rural placement. Med J Aust 2013; 199: 779-782. <MJA full text>
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              Digital rectal examination: indications and technique

              Christopher S Pokorny
              Med J Aust 2017; 207 (4): . || doi: 10.5694/mja17.00373
              Published online: 21 August 2017

              Digital rectal examination (DRE) is an important component of the physical examination. It is essential when someone presents with rectal bleeding, acute abdominopelvic pain (to check for pelvic peritoneal irritation) or other symptoms suggestive of anorectal or prostatic pathology (Box 1). Indeed, in days gone by, some physicians lived by the maxim: “if you don’t put your finger in, you put your foot in it” (attributed to Hamilton Bailey, English surgeon, 1894–1961).


              • South Western Sydney Medical School, UNSW Sydney, Sydney, NSW


              Correspondence: c.pokorny@unsw.edu.au
              Competing interests:

              No relevant disclosures.

              • 1. Tantiphlachiva K, Rao P, Attaluri A, et al. Digital rectal examination is a useful tool for identifying patients with dyssynergia. Clin Gastroenterol Hepatol 2010; 11: 955-960.
              • 2. Wong RK, Drossman DA, Bharucha AE, et al. The digital rectal examination: a multicentre survey of physicians’ and students’ perceptions and practice patterns. Am J Gastroenterol 2012; 107: 1157-1163.
              • 3. Talley NJ. How to do and interpret a rectal examination in gastroenterology. Am J Gastroenterol 2008; 103: 820-822.
              • 4. Hoepffner N, Shastri YM, Hanisch E, et al. Comparative evaluation of a new bedside faecal occult blood test in a prospective multicentre study. Aliment Pharmacol Ther 2006; 23: 145-154.
              • 5. Hoogendam A, Buntinx F, de Vet HC. The diagnostic value of digital rectal examination in primary care screening for prostate cancer: a meta-analysis. Fam Pract 1999; 16: 621.

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                No smoker left behind: it’s time to tackle tobacco in Australian priority populations

                Billie Bonevski, Ron Borland, Christine L Paul, Robyn L Richmond, Michael Farrell, Amanda Baker, Coral E Gartner, Sharon Lawn, David P Thomas and Natalie Walker
                Med J Aust 2017; 207 (4): . || doi: 10.5694/mja16.01425
                Published online: 21 August 2017

                A truly comprehensive approach to tobacco control should include interventions targeting high risk groups

                Australia is a world leader in tobacco control as a result of implementing the strong tobacco control strategies in the World Health Organization Framework Convention on Tobacco Control (http://www.who.int/fctc/en). The Australian adult daily smoking prevalence is 14%1 compared with 31% in 1986,2 with a government goal to reduce this prevalence to 10% by 2020.3 Recently employed tobacco control strategies include increased taxation and plain cigarette pack legislation, supported by strong legislative, economic and community commitment to significantly reduce tobacco use in our society. These strategies motivate smokers to quit. For example, data from the 2007 National Drug Strategy Household Survey4 indicate that high cigarette prices are a key motivator to attempt to quit or reduce the number of cigarettes smoked.


                • 1 University of Newcastle, Newcastle, NSW
                • 2 Cancer Council Victoria, Melbourne, VIC
                • 3 UNSW Sydney, Sydney, NSW
                • 4 National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW
                • 5 University of Queensland, Brisbane, QLD
                • 6 Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, SA
                • 7 Menzies School of Health Research, Darwin, NT
                • 8 National Institute for Health Innovation, University of Auckland, Auckland, NZ


                Competing interests:

                No relevant disclosures.

                • 1. Australian Institute of Health and Welfare. National Drug Strategy Household Survey detailed report, 2013 (AIHW Cat. No. PHE 183; Drug Statistics Series No. 28). Canberra: AIHW, 2014. http://aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129549848 (accessed Dec 2016).
                • 2. Greenhalgh EM, Bayly M, Winstanley MH. 1.3 Prevalence of smoking—adults. In: Scollo MM, Winstanley MH, editors. Tobacco in Australia: facts and issues. Melbourne: Cancer Council Victoria, 2015. http://www.tobaccoinaustralia.org.au/chapter-1-prevalence/1-3-prevalence-of-smoking-adults (accessed July 2017).
                • 3. Intergovernmental Committee on Drugs. National Tobacco Strategy 2012–2018. Canberra: Commonwealth of Australia, 2012. http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/D4E3727950BDBAE4CA257AE70003730C/$File/National%20Tobacco%20Strategy%202012-2018.pdf (accessed Dec 2016).
                • 4. Australian Institute of Health and Welfare. 2007 National Drug Strategy Household Survey: detailed findings (AIHW Cat. No. PHE 107). Canberra: AIHW, 2008. http://www.aihw.gov.au/publication-detail/?id=6442468195 (accessed Dec 2016).
                • 5. Australian Institute of Health and Welfare. Australian Burden of Disease Study: Impact and causes of illness and death in Australia 2011 (Australian Burden of Disease Study Series No. 3; BOD 4). Canberra: AIHW, 2016. http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129555176 (accessed Dec 2016).
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                • 11. Malone RE. The race to a tobacco endgame. Tob Control 2016; 25: 607-608.
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                • 15. Baker AL, Richmond R, Kay-Lambkin FJ, et al. Randomized controlled trial of a healthy lifestyle intervention among smokers with psychotic disorders. Nicotine Tob Res 2015; 17: 946-954.
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                  Computed tomography colonography: underutilised in Australia

                  Richard M Mendelson, Tom Sutherland and Andrew Little, Abdominal Radiology Group of Australia and New Zealand
                  Med J Aust 2017; 207 (4): . || doi: 10.5694/mja16.00684
                  Published online: 21 August 2017

                  CTC is a safe and accurate cancer detection technique widely used overseas but underused here

                  Computed tomography colonography (CTC), also known as virtual colonoscopy, is a minimally invasive method for examining the whole colon using computed tomography to acquire images after distension of the colon with air or carbon dioxide through a small rectal tube. Dedicated software enables 2D and 3D fly-through models for interpretation. No sedation is required. CTC has been used since the mid-1990s, the earliest Australian experience being in 1996–1997.1


                  • 1 Royal Perth Hospital and University of Western Australia, Perth, WA
                  • 2 University of Melbourne and St Vincent's Hospital, Melbourne, Vic


                  Acknowledgements: 

                  This article is written on behalf of the ARGANZ. Members of the ARGANZ are listed in the online Appendix.

                  Competing interests:

                  No relevant disclosures.

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                  • 13. Taylor SA, Halligan S, Saunders BP, et al. Use of multidetector-row CT colonography for detection of colorectal neoplasia in patients referred via the Department of Health “2-Week-wait” initiative. Clin Radiol 2003; 58: 855-861.
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                  • 18. National Institute of Health and Welfare. National Bowel Cancer Screening Program monitoring report: phase 2, July 2008–June 2011 (AIHW Cat. No. CAN 61; Cancer Series No. 65). Canberra: AIHW; 2012. http://www.aihw.gov.au/publication-detail/?id=10737421408 (accessed June 2017).

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                    Faecal microbiota transplantation for Clostridium difficile-associated diarrhoea: a systematic review of randomised controlled trials

                    Paul Moayyedi, Yuhong Yuan, Harith Baharith and Alexander C Ford
                    Med J Aust 2017; 207 (4): . || doi: 10.5694/mja17.00295
                    Published online: 14 August 2017

                    Abstract

                    Objectives: Faecal microbiota transplantation (FMT) has emerged as a useful approach for treating Clostridium difficile-associated diarrhoea (CDAD). Randomised controlled trials (RCTs) have recently evaluated its effectiveness, but systematic reviews have focused on evidence from case series. We therefore conducted a systematic review and meta-analysis of RCTs evaluating the effectiveness of FMT for treating CDAD.

                    Study design: We included RCTs that primarily recruited adults with CDAD and compared the effectiveness of FMT with that of placebo, antibiotic therapy, or autologous stool transplantation, or compared different preparations or modes of delivery of FMT. Dichotomous symptom data were pooled to calculate a relative risk (RR) of CDAD persisting after therapy, and the number needed to treat (NNT).

                    Data sources: MEDLINE, EMBASE, and the Cochrane Controlled Trials Register and Database of Systematic Reviews were searched to 6 February 2017.

                    Data synthesis: We identified ten RCTs that evaluated the treatment of a total of 657 patients with CDAD. Five RCTs compared FMT with placebo (including autologous FMT) or vancomycin treatment (total of 284 patients); FMT was statistically significantly more effective (RR, 0.41; 95% CI, 0.22–0.74; NNT, 3; 95% CI, 2–7). Heterogeneity across studies was significant (I2 = 61%); this heterogeneity was attributable to the mode of delivery of FMT, and to the therapy being more successful in European than in North American trials. The other five RCTs evaluated different approaches to FMT therapy. Frozen FMT preparations were as efficacious as fresh material in one RCT, but the numbers of patients in the remaining RCTs were too small to allow definitive conclusions.

                    Conclusions: Moderate quality evidence from RCT trials indicates that FMT is more effective in patients with CDAD than vancomycin or placebo. Further investigations are needed to determine the best route of administration and FMT preparation.

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                    • 1 McMaster University, Hamilton, ON, Canada
                    • 2 Leeds Gastroenterology Institute, St James's University Hospital, Leeds, United Kingdom
                    • 3 Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom


                    Correspondence: moayyep@mcmaster.ca
                    Competing interests:

                    No relevant disclosures.

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                      Optimising assessment of kidney function when managing localised renal masses

                      Robert J Ellis, Andre Joshi, Keng L Ng, Ross S Francis, Glenda C Gobe and Simon T Wood
                      Med J Aust 2017; 207 (3): . || doi: 10.5694/mja17.00161
                      Published online: 7 August 2017

                      Summary

                       

                      • Increased early and incidental detection, improved surgical techniques and technological advancement mean that the management of renal mass lesions is constantly evolving.
                      • The treatment of choice for renal mass lesions has historically been radical nephrectomy.
                      • Partial nephrectomy is now recommended for localised renal masses, owing to favourable renal functional outcomes.
                      • Ablative renal surgery confers a significant risk of chronic kidney disease.
                      • There are few studies assessing long term outcomes of nephrectomy on renal outcomes, and virtually no studies assessing long term outcomes for less invasive therapies such as ablation.
                      • Unless a renal mass is clearly benign on imaging, management decisions will be made with an assumption of malignancy. The content of this review applies to both benign and malignant renal mass lesions.
                      • We advocate for improved strategies for kidney function assessment and risk stratification, early targeted referral, and regular screening for chronic kidney disease for all patients after surgery.

                       


                      • 1 University of Queensland Diamantina Institute, Translational Research Institute, Brisbane, QLD
                      • 2 Princess Alexandra Hospital, Brisbane, QLD
                      • 3 Australian Prostate Cancer Research Centre, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD
                      • 4 NHMRC Chronic Kidney Disease Centre for Research Excellence (CKD.QLD), University of Queensland, Brisbane, QLD


                      Correspondence: r.ellis1@uq.edu.au
                      Acknowledgements: 

                      Robert Ellis was supported by an Australian Government Research Training Scholarship.

                      Competing interests:

                      No relevant disclosures.

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