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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).

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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).
      • 6. Australian Bureau of Statistics. National Health Survey: first results, 2014-15 (Cat. No. 4364.0.55.001). Canberra: ABS, 2016. http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4364.0.55.001Main+Features100012014-15?OpenDocument (accessed Dec 2016).
      • 7. Baker AL, Ivers RG, Bowman JA, et al. Where there’s smoke, there’s fire: high prevalence of smoking among some sub-populations and recommendations for intervention. Drug Alcohol Rev 2006; 25: 85-96.
      • 8. Butler TG, Yap L. Smoking bans in prison: time for a breather? Med J Aust 2015; 203: 313. <MJA full text>
      • 9. Couzos S, Nicholson AK, Hunt JM, et al. Talking About The Smokes: a large-scale community-based participatory research project. Med J Aust 2015: 202 (10 Suppl): S13-S19. <MJA full text>
      • 10. Cooper J, Mancuso S, Borland R, et al. Tobacco smoking among people living with a psychotic illness: the second Australian survey of psychosis. Aust N Z J Psychiatry 2012; 46: 851-863.
      • 11. Malone RE. The race to a tobacco endgame. Tob Control 2016; 25: 607-608.
      • 12. Twyman L, Bonevski B, Paul C, et al. Perceived barriers to smoking cessation in selected socioeconomically disadvantaged groups: A systematic review of the qualitative and quantitative literature. BMJ Open 2014; 4: 1-15.
      • 13. Guillaumier A, Bonevski B, Paul C. Tobacco health warning messages on plain cigarette packs and in television campaigns: a qualitative study with Australian socioeconomically disadvantaged smokers. Health Educ Res 2015; 30: 57-66.
      • 14. Walters EH, Barnsley K. Tobacco-free generation legislation. Med J Aust 2015; 202: 509. <MJA full text>
      • 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.
      • 16. Franck C, Filion KB, Kimmelman J, et al. Ethical considerations of e-cigarette use for tobacco harm reduction. Respir Res 2016; 17: 53.
      • 17. Twyman L, Bonevski B, Paul C, et al. Electronic cigarettes: awareness, recent use, and attitudes within a sample of socioeconomically disadvantaged Australian smokers. Nicotine Tob Res 2016; 18: 670-677.
      • 18. O’Brien B, Knight-West O, Walker N, et al. E-cigarettes for smoking reduction or cessation in people with mental illness: secondary analysis of data from the ASCEND trial. Tob Induc Dis 2015; 13: 5.
      • 19. Bonevski B, Guillaumier A, Shakeshaft A, et al. An organisational change intervention for increasing the delivery of smoking cessation support in addiction treatment centres: study protocol for a randomized controlled trial. Trials 2016; 17: 290.
      • 20. Ministry of Health. Health targets: better help for smokers to quit. http://www.health.govt.nz/new-zealand-health-system/health-targets/about-health-targets/health-targets-better-help-smokers-quit (accessed July 2017).
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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.

        • 1. Mendelson RM, Foster NM, Edwards JT, et al. Virtual colonoscopy compared with conventional colonoscopy: a developing technology. Med J Aust 2000; 173: 472-475.
        • 2. Pickhardt PJ, Choi JR, Hwang I, et al. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med 2003; 349: 2191-2200.
        • 3. Johnson CD. Accuracy of CT colonography for detection of large adenomas and cancers (ACRIN trial). N Engl J Med 2008; 359: 1207-1217.
        • 4. de Haan MC, Pickhardt PJ, Stoker J. CT colonography: accuracy, acceptance, safety and position in organised population screening. Gut 2015; 64: 342-350.
        • 5. Halligan S, Altman DG, Taylor SA, et al. CT colonography in the detection of colorectal polyps and cancer: systematic review, meta-analysis, and proposed minimum data set for study level reporting. Radiology 2005; 237: 893-904.
        • 6. Pickhardt PJ, Hassan C, Halligan S, Marmo R. Colorectal cancer: CT colonography and colonoscopy for detection — systematic review and meta-analysis. Radiology 2011; 259: 393-405.
        • 7. Burling D. CT colonography standards. Clin Radiol 2010; 65: 474-480.
        • 8. Zalis ME, Barish MA, Choi JR, et al. CT colonography reporting and data system: a consensus proposal. Radiology 2005; 236: 3-9.
        • 9. Neri E, Halligan S, Hellström M, et al. The second ESGAR consensus statement on CT colonography. Eur Radiol 2013; 23: 720-729.
        • 10. Halligan S, Wooldrage K, Dadswell E, et al. Computed tomographic colonography versus barium enema for diagnosis of colorectal cancer or large polyps in symptomatic patients (SIGGAR): a multicentre randomised trial. Lancet 2013; 381: 1185-1193.
        • 11. The 2007 Recommendations of the International Commission on Radiological Protection. ICRP Publication 103. Ann ICRP 2007; 37: 1-332
        • 12. Spada C, Stoker J, Alarcon O, et al. Clinical indications for computed tomographic colonography: European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastrointestinal and Abdominal Radiology (ESGAR) Guideline. Eur Radiol 2015; 25: 331-345.
        • 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.
        • 14. Behrens C, Stevenson G, Eddy R, et al. The benefits of computed tomographic colonography in reducing a long colonoscopy waiting list. Can Assoc Radiol J 2010; 61: 33-40.
        • 15. Sanders AD, Stevenson C, Pearson J, et al. A novel pathway for investigation of colorectal symptoms with colonoscopy or computed tomography colonography. N Z Med J 2013; 126: 45-57.
        • 16. Pyenson B, Pickhardt PJ, Sawhney TG, Berrios M. Medicare cost of colorectal cancer screening: CT colonography vs. optical colonoscopy. Abdom Imaging 2015; 40: 2966-2976.
        • 17. Pickhardt PJ. CT colonography for population screening: ready for prime time? Dig Dis Sci 2015; 60: 647-659.
        • 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.

          • 1. Hall I, O’Toole E. Intestinal flora in newborn infants with a description of a new pathogenic anaerobe, Bacillus difficilis. Am J Dis Child 1935; 49: 390.
          • 2. Heinlen L, Ballard JD. Clostridium difficile infection. Am J Med Sci 2010; 340: 247-252.
          • 3. Bartlett JG. Clostridium difficile: history of its role as an enteric pathogen and the current state of knowledge about the organism. Clin Infect Dis. 1994; 18 (Suppl 4): S265-S272.
          • 4. Reveles KR, Lee GC, Boyd NK, Frei CR. The rise in Clostridium difficile infection incidence among hospitalized adults in the United States: 2001–2010. Am J Infect Control 2014; 42: 1028-1032.
          • 5. Leffler DA, Lamont JT. Clostridium difficile infection. N Engl J Med 2015; 372: 1539-1548.
          • 6. Slimings C, Armstrong P, Beckingham WD, et al. Increasing incidence of Clostridium difficile infection, Australia, 2011–2012. Med J Aust 2014; 200: 272-276. <MJA full text>
          • 7. O'Connor JR, Johnson S, Gerding DN. Clostridium difficile infection caused by the epidemic BI/NAP1/027 strain. Gastroenterology 2009; 136: 1913-1924.
          • 8. Lessa FC, Mu Y, Bamberg WM, et al. Burden of Clostridium difficile in the United States. N Engl J Med 2015; 372: 825-834.
          • 9. Zhang F, Luo W, Shi Y, et al. Should we standardize the 1700-year old fecal microbiota transplantation? Am J Gastroenterol 2012; 107: 1755.
          • 10. Borody TJ, Brandt LJ, Paramsothy S. Therapeutic faecal microbiota transplantation: current status and future developments. Curr Opin Gastroenterol 2014; 30: 97-105.
          • 11. Debast SB, Bauer MP, Kuipers EJ. European Society of Clinical Microbiology and Infectious Diseases: update of the treatment guidance document for Clostridium difficile infection. Clin Microbial Infect 2014; 20 (Suppl 2): 1-26.
          • 12. Cammarota G, Ianiro G, Tilg H, et al. European consensus conference on faecal microbiota transplantation in clinical practice. Gut 2017; 66: 569-580.
          • 13. Moayyedi P, Marshall JK, Yuan Y, Hunt R. Canadian Association of Gastroenterology position statement: fecal microbiota transplant therapy. Can J Gastroenterol Hepatol 2014; 28: 66-68.
          • 14. Cheng AC, Ferguson JK, Richards MJ, et al. Australasian Society for Infectious Diseases guidelines for the diagnosis and treatment of Clostridium difficile infection. Med J Aust 2011; 194: 353-358. <MJA full text>
          • 15. Drekonja D, Reich J, Gezahegn S, et al. Fecal microbiota transplantation for Clostridium difficile infection. a systematic review. Ann Intern Med 2015; 162: 630-638.
          • 16. Higgins JPT, Churchill R, Chandler J, Cumpston MS (editors). Cochrane handbook for systematic reviews of interventions; version 5.2 (updated Feb 2017), Cochrane, 2017. http://training.cochrane.org/ (accessed June 2017).
          • 17. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986; 7: 177-188.
          • 18. Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003; 327: 557-560.
          • 19. Moayyedi P. Meta-analysis: can we mix apples and oranges? Am J Gastroenterol 2004; 99: 2297-2301.
          • 20. Sterne JA, Sutton AJ, Ioannidis JP, et al. Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials. BMJ 2011; 343: d4002.
          • 21. Egger M, Davey-Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997; 315: 629-634.
          • 22. van Nood E, Vrieze A, Nieuwdorp M, et al. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Engl J Med 2013; 368: 407-415.
          • 23. Cammarota G, Masucci L, Ianiro G, et al. Randomised clinical trial: faecal microbiota transplantation by colonoscopy vs. vancomycin for the treatment of recurrent Clostridium difficile infection. Aliment Pharmacol Ther 2015; 41: 835-843.
          • 24. Kelly CR, Khoruts A, Staley C, et al. Effect of fecal microbiota transplantation on recurrence in multiply recurrent Clostridium difficile infection. Ann Intern Med 2016; 165: 609-616.
          • 25. Orenstein R, Dubberke E, Lee CH, et al. RBX2660, a microbiota-based drug for the prevention of recurrent Clostridium difficile infection, is safe and effective: results from a randomised, double-blinded, placebo-controlled trial (abstract LB08). 24th UEG Week 2016; Vienna (Austria), 17–19 Oct 2016. United European Gastroenterol J 2016; 4: 802.
          • 26. Hota SS, Sales V, Tomlinson G, et al. Oral vancomycin followed by fecal transplantation versus tapering oral vancomycin treatment for recurrent Clostridium difficile infection: an open-label, randomized controlled trial. Clin Infect Dis 2017; 64: 265-271.
          • 27. Youngster I, Sauk J, Pindar C, et al. Fecal microbiota transplant for relapsing Clostridium difficile infection using a frozen inoculum from unrelated donors: a randomized, open-label, controlled pilot study. Clin Infect Dis 2014; 58: 1515-1522.
          • 28. Allegretti JR, Fischer M, Papa E, et al. Fecal microbiota transplantation delivered via oral capsules achieves microbial engraftment similar to traditional delivery modalities: safety efficacy and engraftment results from a multi-center cluster randomized dose-finding study (abstract Su1738). Digestive Disease Week (DDW) 2016; San Diego (USA), 21–24 May 2016. Gastroenterology 2016; 150 (Suppl 1): S540.
          • 29. Kao D, Roach B, Hotte N, et al. A prospective dual center, randomized trial comparing colonoscopy versus capsule delivered fecal microbiota transplantation (FMT) in the management of recurrent Clostridium difficile infection (RCDAD) (poster A117). Canadian Digestive Diseases Week 2016; Montreal (Canada), 26–29 Feb 2016. Can J Gastroenterol Hepatol 2016: article 4792898, p. 71.
          • 30. Lee CH, Steiner T, Petrof EO, et al. Frozen vs fresh fecal microbiota transplantation and clinical resolution of diarrhea in patients with recurrent Clostridium difficile infection a randomized clinical trial. JAMA 2016; 315: 142-149.
          • 31. Jiang ZD, Ajami NJ, Petrosino JF, et al. Randomised clinical trial: faecal microbiota transplantation for recurrent Clostridum difficile infection — fresh, or frozen, or lyophilised microbiota from a small pool of healthy donors delivered by colonoscopy. Aliment Pharmacol Ther 2017; 45: 899-908.
          • 32. Guyatt GH, Oxman AD, Vist G, et al; for the GRADE Working Group. Rating quality of evidence and strength of recommendations GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008; 336: 924-926.
          • 33. Rossen NG, MacDonald JK, de Vries EM, et al. Fecal microbiota transplantation as novel therapy in gastroenterology: a systematic review. World J Gastroenterol 2015; 21: 5359-5371.
          • 34. Chapman BC, Moore HB, Overby DM, et al. Fecal microbiota transplant in patients with Clostridium difficile infection: a systematic review. Acute Care Surg 2016; 81: 756-764.
          • 35. Kassam Z, Lee CH, Yuan Y, Hunt RH. Fecal microbiota transplantation for Clostridium difficile infection: systematic review and meta-analysis. Am J Gastroenterol 2013; 108: 500-508.
          • 36. Borody TJ, George L, Andrews P, et al. Bowel-flora alteration: a potential cure for inflammatory bowel disease and irritable bowel syndrome? Med J Aust 1989; 150: 604.
          • 37. Costello SP, Conlon MA, Vuaran MS, et al. Faecal microbiota transplant for recurrent Clostridium difficile infection using long-term frozen stool is effective: clinical efficacy and bacterial viability data. Aliment Pharmacol Ther 2015; 42: 1011-1018.
          • 38. Borody TJ, Fischer M, Mitchell S, Campbell J. Fecal microbiota transplantation in gastrointestinal disease: 2015 update and the road ahead. Expert Rev Gastroenterol Hepatol 2015; 9: 1379-1391.
          • 39. University of Texas Health Science Center, Houston. Fecal microbiota transplantation to treat recurrent C. difficile associated diarrhea via retention enema or oral route. https://clinicaltrials.gov/ct2/show/NCT02449174 (accessed June 2017).
          • 40. Louie TJ, Miller MA, Mullane KM, et al. Fidaxomicin versus vancomycin for Clostridium difficile infection. N Engl J Med 2011; 364: 422-431.
          • 41. Baxter M, Ahmad T, Colville A, Sheridan R. Fatal aspiration pneumonia as a complication of fecal microbiota transplantation. Clin Inf Dis 2015; 61: 136-137.
          Online responses are no longer available. Please refer to our instructions for authors page for more information.

            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.

            • 1. Znaor A, Lortet-Tieulent J, Laversanne M, et al. International variations and trends in renal cell carcinoma incidence and mortality. Eur Urol 2015; 67: 519-530.
            • 2. Kidney Disease: Improving Global Outcomes CKD Workgroup. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl 2013; 3: 1-150.
            • 3. Kim SP, Murad MH, Thompson RH, et al. Comparative effectiveness for survival and renal function of partial and radical nephrectomy for localized renal tumors: a systematic review and meta-analysis. J Urol 2012; 188: 51-57.
            • 4. Australian Institute of Health and Welfare. Cancer Incidence Projections: Australia, 2011-2020 (AIHW Cat. No. CAN 62; Cancer Series No. 66). Canberra: AIHW; 2012.
            • 5. Ta AD, Bolton DM, Dimech MK, et al. Contemporary management of renal cell carcinoma (RCC) in Victoria: implications for longer term outcomes and costs. BJU Int 2013; 112 Suppl 2: 36-43.
            • 6. Satasivam P, Reeves F, Rao K, et al. Patients with medical risk factors for chronic kidney disease are at increased risk of renal impairment despite the use of nephron-sparing surgery. BJU Int 2015; 116: 590-595.
            • 7. Srigley JR, Delahunt B, Eble JN, et al. The International Society of Urological Pathology (ISUP) Vancouver classification of renal neoplasia. Am J Surg Pathol 2013; 37: 1469-1489.
            • 8. Samaratunga H, Gianduzzo T, Delahunt B. The ISUP system of staging, grading and classification of renal cell neoplasia. J Kidney Cancer VHL 2014; 1: 26-39.
            • 9. Amin MB, Edge S, Greene F, et al. AJCC Cancer Staging Manual. 8th ed. New York: Springer, 2017.
            • 10. Ljungberg B, Bensalah K, Canfield S, et al. EAU guidelines on renal cell carcinoma: 2014 update. Eur Urol 2015; 67: 913-924.
            • 11. Campbell SC, Novick AC, Belldegrun A, et al. Guideline for management of the clinical T1 renal mass. J Urol 2009; 182: 1271-1279.
            • 12. Sanchez-Martin FM, Millan-Rodriguez F, Urdaneta-Pignalosa G, et al. Small renal masses: incidental diagnosis, clinical symptoms, and prognostic factors. Adv Urol 2008: 310694.
            • 13. Pierorazio PM, Johnson MH, Ball MW, et al. Five-year analysis of a multi-institutional prospective clinical trial of delayed intervention and surveillance for small renal masses: the DISSRM registry. Eur Urol 2015; 68: 408-415.
            • 14. Kim HL, Belldegrun AS, Freitas DG, et al. Paraneoplastic signs and symptoms of renal cell carcinoma: implications for prognosis. J Urol 2003; 170: 1742-1746.
            • 15. Yap NY, Ng KL, Ong TA, et al. Clinical prognostic factors and survival outcome in renal cell carcinoma patients — a Malaysian single centre perspective. Asian Pac J Cancer Prev 2013; 14: 7497-7500.
            • 16. Giannarini G, Petralia G, Thoeny HC. Potential and limitations of diffusion-weighted magnetic resonance imaging in kidney, prostate, and bladder cancer including pelvic lymph node staging: a critical analysis of the literature. Eur Urol 2012; 61: 326-340.
            • 17. Fowler C, Reznek R. The indeterminate renal mass. Imaging 2001; 13: 27-43.
            • 18. Pallwein-Prettner L, Flöry D, Rotter CR, et al. Assessment and characterisation of common renal masses with CT and MRI. Insights Imaging 2011; 2: 543-556.
            • 19. Bosniak MA. The Bosniak renal cyst classification: 25 years later. Radiology 2012; 262: 781-785.
            • 20. Warren KS, McFarlane J. The Bosniak classification of renal cystic masses. BJU Int 2005; 95: 939-942.
            • 21. Frank I, Blute ML, Cheville JC, et al. Solid renal tumors: an analysis of pathological features related to tumor size. J Urol 2003; 170: 2217-2220.
            • 22. Sankineni S, Brown A, Cieciera M, et al. Imaging of renal cell carcinoma. Urol Oncol 2016; 34: 147-155.
            • 23. Mueller-Lisse UG, Mueller-Lisse UL. Imaging of advanced renal cell carcinoma. World J Urol 2010; 28: 253-261.
            • 24. Rhee H, Blazak J, Tham CM, et al. Pilot study: use of gallium-68 PSMA PET for detection of metastatic lesions in patients with renal tumour. EJNMMI Res 2016; 6: 76.
            • 25. Okhunov Z, Rais-Bahrami S, George AK, et al. The comparison of three renal tumor scoring systems: C-Index, P.A.D.U.A., and R.E.N.A.L. nephrometry scores. J Endourol 2011; 25: 1921-1924.
            • 26. Patel HD, Johnson MH, Pierorazio PM, et al. Diagnostic accuracy and risks of biopsy in the diagnosis of a renal mass suspicious for localized renal cell carcinoma: systematic review of the literature. J Urol 2016; 195: 1340-1347.
            • 27. Marconi L, Dabestani S, Lam TB, et al. Systematic review and meta-analysis of diagnostic accuracy of percutaneous renal tumour biopsy. Eur Urol 2016; 69: 660-673.
            • 28. Andersen MF, Norus TP. Tumor seeding with renal cell carcinoma after renal biopsy. Urol Case Rep 2016; 9: 43-44.
            • 29. Masson-Lecomte A, Bensalah K, Seringe E, et al. A prospective comparison of surgical and pathological outcomes obtained after robot-assisted or pure laparoscopic partial nephrectomy in moderate to complex renal tumours: results from a French multicentre collaborative study. BJU Int 2013; 111: 256-263.
            • 30. Choi JE, You JH, Kim DK, et al. Comparison of perioperative outcomes between robotic and laparoscopic partial nephrectomy: a systematic review and meta-analysis. Eur Urol 2015; 67: 891-901.
            • 31. Smaldone MC, Kutikov A, Egleston BL, et al. Small renal masses progressing to metastases under active surveillance: a systematic review and pooled analysis. Cancer 2012; 118: 997-1006.
            • 32. Su MZ, Memon F, Lau HM, et al. Safety, efficacy and predictors of local recurrence after percutaneous radiofrequency ablation of biopsy-proven renal cell carcinoma. Int Urol Nephrol 2016; 48: 1609-1616.
            • 33. Nielsen TK, Lagerveld BW, Keeley F, et al. Oncological outcomes and complication rates after laparoscopic-assisted cryoablation: a European Registry for Renal Cryoablation (EuRECA) multi-institutional study. BJU Int 2017; 119: 390-395.
            • 34. Lane BR, Demirjian S, Derweesh IH, et al. Survival and functional stability in chronic kidney disease due to surgical removal of nephrons: importance of the new baseline glomerular filtration rate. Eur Urol 2015; 68: 996-1003.
            • 35. Johnson DW, Atai E, Chan M, et al. KHA-CARI guideline: early chronic kidney disease: detection, prevention and management. Nephrology 2013; 18: 340-350.
            • 36. Jeon HG, Jeong IG, Lee JW, et al. Prognostic factors for chronic kidney disease after curative surgery in patients with small renal tumors. Urology 2009; 74: 1064-1068.
            • 37. Jeon HG, Choo SH, Jeong BC, et al. Uric acid levels correlate with baseline renal function and high levels are a potent risk factor for postoperative chronic kidney disease in patients with renal cell carcinoma. J Urol 2013; 189: 1249-1254.
            • 38. Torricelli FC, Danilovic A, Marchini GS, et al. Can we predict which patients will evolve to chronic kidney disease after nephrectomy for cortical renal tumors? Int Braz J Urol 2012; 38: 637-643; discussion 644.
            • 39. Malcolm JB, Bagrodia A, Derweesh IH, et al. Comparison of rates and risk factors for developing chronic renal insufficiency, proteinuria and metabolic acidosis after radical or partial nephrectomy. BJU Int 2009; 104: 476-481.
            • 40. Klarenbach S, Moore RB, Chapman DW, et al. Adverse renal outcomes in subjects undergoing nephrectomy for renal tumors: a population-based analysis. Eur Urol 2011; 59: 333-339.
            • 41. Jeon HG, Choo SH, Sung HH, et al. Small tumour size is associated with new-onset chronic kidney disease after radical nephrectomy in patients with renal cell carcinoma. Eur J Cancer 2014; 50: 64-69.
            • 42. Zabor EC, Furberg H, Mashni J, et al. Factors associated with recovery of renal function following radical nephrectomy for kidney neoplasms. Clin J Am Soc Nephrol 2016; 11: 101-107.
            • 43. Tangri N, Stevens LA, Griffith J, et al. A predictive model for progression of chronic kidney disease to kidney failure. JAMA 2011; 305: 1553-1559.
            • 44. Weight CJ, Larson BT, Fergany AF, et al. Nephrectomy induced chronic renal insufficiency is associated with increased risk of cardiovascular death and death from any cause in patients with localized cT1b renal masses. J Urol 2010; 183: 1317-1323.
            • 45. Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med 2009; 150: 604-612.
            • 46. Kidney Disease: Improving Global Outcomes AKI Workgroup. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl 2012; 2: 1-138.
            • 47. Hu SL, Chang A, Perazella MA, et al. The nephrologist's tumor: basic biology and management of renal cell carcinoma. J Am Soc Nephrol 2016; 27: 2227-2237.
            • 48. Henriksen KJ, Meehan SM, Chang A. Nonneoplastic kidney diseases in adult tumor nephrectomy and nephroureterectomy specimens: common, harmful, yet underappreciated. Arch Pathol Lab Med 2009; 133: 1012-1025.
            • 49. Cho A, Lee JE, Kwon GY, et al. Post-operative acute kidney injury in patients with renal cell carcinoma is a potent risk factor for new-onset chronic kidney disease after radical nephrectomy. Nephrol Dial Transplant 2011; 26: 3496-3501.
            • 50. Trehan A. Comparison of off-clamp partial nephrectomy and on-clamp partial nephrectomy: a systematic review and meta-analysis. Urol Int 2014; 93: 125-134.
            • 51. Mir MC, Pavan N, Parekh DJ. Current paradigm for ischemia in kidney surgery. J Urol 2016; 195: 1655-1663.
            • 52. Chung JS, Son NH, Byun SS, et al. Trends in renal function after radical nephrectomy: a multicentre analysis. BJU Int 2014; 113: 408-415.
            • 53. Kidney Health Australia. Chronic kidney disease (CKD) management in general practice. 3rd ed. Melbourne: KHA, 2015. http://kidney.org.au/health-professionals/prevent/chronic-kidney-disease-management-handbook (accessed June 2017).
            Online responses are no longer available. Please refer to our instructions for authors page for more information.

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

              Stephen J Robson and Caroline M de Costa
              Med J Aust 2017; 207 (3): . || doi: 10.5694/mja17.00449
              Published online: 7 August 2017

              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).
              Online responses are no longer available. Please refer to our instructions for authors page for more information.

                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

                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.
                Online responses are no longer available. Please refer to our instructions for authors page for more information.

                  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

                  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


                  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).
                  Online responses are no longer available. Please refer to our instructions for authors page for more information.

                    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

                    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


                    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.
                    Online responses are no longer available. Please refer to our instructions for authors page for more information.

                      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

                      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.
                      • 5. White J. A clinician’s guide to Australian venomous bites and stings: incorporating the updated CSL antivenom handbook. Melbourne: CSL, 2012.
                      • 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.
                      • 8. Jelinek GA, Breheny FX. Ten years of snake bites at Fremantle Hospital. Med J Aust 1990; 153: 658-661.
                      • 9. Mead HJ, Jelinek GA. Suspected snakebite in children: a study of 156 patients over 10 years. Med J Aust 1996; 164: 467-470. <MJA full text>
                      • 10. Tibballs J. Diagnosis and treatment of confirmed and suspected snake bite. Implications from an analysis of 46 paediatric cases. Med J Aust 1992; 156: 270-274.
                      • 11. Fisher MM, Bowey CJ. Urban envenomation. Med J Aust 1989; 150: 695-698.
                      • 12. Barrett R, Little M. Five years of snake envenoming in far north Queensland. Emerg Med (Fremantle) 2003; 15: 500-510.
                      • 13. Currie BJ. Snakebite in tropical Australia: a prospective study in the “Top End” of the Northern Territory. Med J Aust 2004; 181: 693-697. <MJA full text>
                      • 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.
                      • 17. Kulawickrama S, O’Leary MA, Hodgson WC, et al. Development of a sensitive enzyme immunoassay for measuring taipan venom in serum. Toxicon 2010; 55: 1510-1518.
                      • 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.
                      • 19. Ireland G, Brown SG, Buckley NA, et al. Changes in serial laboratory test results in snakebite patients: when can we safely exclude envenoming? Med J Aust 2010; 193: 285-290. <MJA full text>
                      • 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.
                      • 21. Brown SG. Clinical features and severity grading of anaphylaxis. J Allergy Clin Immunol 2004; 114: 371-376.
                      • 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.
                      • 24. Isbister GK, O’Leary MA, Elliott M, Brown SG. Tiger snake (Notechis spp) envenoming: Australian Snakebite Project (ASP-13). Med J Aust 2012; 197: 173-177. <MJA full text>
                      • 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.
                      • 26. Churchman A, O’Leary MA, Buckley NA, et al. Clinical effects of red-bellied black snake (Pseudechis porphyriacus) envenoming and correlation with venom concentrations: Australian Snakebite Project (ASP-11). Med J Aust 2010; 193: 696-700. <MJA full text>
                      • 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.
                      • 28. Nimorakiotakis VB, Winkel KD. Prospective assessment of the false positive rate of the Australian snake venom detection kit in healthy human samples. Toxicon 2016; 111: 143-146.
                      • 29. Isbister GK, Brown SG, Page CB, et al. Snakebite in Australia: a practical approach to diagnosis and treatment. Med J Aust 2013; 199: 763-768. <MJA full text>
                      • 30. Maduwage K, O’Leary MA, Isbister GK. Diagnosis of snake envenomation using a simple phospholipase A2 assay. Sci Rep 2014; 4: 4827.
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