Volume 206 Issue 6

Time to increase our focus on immunising adults

Robert I Menzies · Julie Leask · Jenny Royle · C Raina MacIntyre

An innovative approach to funding primary health care involving collaboration between different levels of government and other stakeholders

Stephen Jan

Aggregated data extracted from computerised general practice records should be used to improve outcomes at patient, health system and population levels

Michael Staff · Chris Roberts · Lynette M March

The first article of this series1 presented a framework to assist in judging the presence of bias: selection bias, or systematic error in how participants are identified or selected; measurement bias, or systematic error in how variables are measured; and analytical bias — also known as confounding — or systematic error in the measure of association or conclusion about causation, due to improper or incomplete analysis. Selection and measurement bias should be managed pre-emptively by good design before the start of the study, but can be detected post hoc by critical appraisal. No statistical method removes the effect of selection or measurement bias post hoc, although there are methods that allow us to model different degrees of bias and evaluate the effect on the measure of association.1 Confounding is slightly different in that it can be adjusted for in the analysis, as long as its sources are understood and measured without too much error. What is confounding? A confounder has been traditionally defined as a variable associated with both the exposure and outcome of interest without being an intermediate on the causal pathway between them, which causes a spurious or distorted estimate of the exposure–outcome association. This may be conceptually difficult to understand in the abstract, so a concrete example is useful. At the beginning of this series,1 we used the example of smoking (exposure) and dementia (outcome), and we postulated that alcohol may be a confounder. In this sense, alcohol is associated with smoking, that is, people who drink also tend to smoke, and alcohol may independently contribute to the risk of dementia. We may decide to study 100 people who smoke and 100 people who do not smoke and follow them over many years for the development of dementia (Box 1). In our study, 30% of people who smoke and 18% of those who do not smoke develop dementia. The relative risk (RR) of developing dementia is therefore 30%/18% = 1.7. However, based on our clinical knowledge, we have identified alcohol as a potential confounder and we want to adjust for this variable in estimating the effect of smoking on dementia. We may perform this adjustment either by including alcohol as a covariate in a regression model or by stratifying on this variable. In this article, we will do the latter because it makes the relationship between the variables more obvious. Stratifying the sample into drinking and non-drinking groups means that we remove the effect of drinking from our analysis. One way to understand this is to consider that within the strata of drinking status, everyone has the same level of drinking; thus, there is no variation in this variable and no potential to influence the outcome. This is a simplification, but it is useful for demonstration purposes. The relationship between smoking and dementia stratified by drinking status is shown in Box 2. The RR of dementia with smoking is one in each stratum of drinking status. How is it that combining two groups that individually show no association between smoking and dementia yields an overall group that shows an association? Summing the frequencies of the respective cells across the two 2 × 2 tables in the strata (Box 2) yields the same numbers as the overall 2 × 2 table (Box 1). To understand how confounding works in this example, we need to see two relationships: Drinking is associated with smoking: in Box 2, (25 + 25)/(25 + 25 + 10 + 10) = 50/70 ∼ 70% of people who drink also smoke, and (5 + 45)/(5 + 45 + 8 + 72) = 50/130 ∼ 40% of people who do not drink smoke. Drinking is associated with dementia: the risk of dementia in people who do not drink (Box 2) is 10%, compared with 50% in people who drink (Box 2). Drinking status is, therefore, a confounder of the relationship between smoking and drinking. Another way of understanding this is to recognise that in the overall table, what is labelled as the smoking group is actually a drinking group, and it is the drinking that is responsible for the development of dementia. We may see this by rearranging the 2 × 2 tables (Box 2) by strata of smoking, and looking at the relationship between drinking and dementia (Box 3). These tables show that the RR of dementia with drinking is 50%/10% = 5, regardless of whether smoking is present or absent, that is, RR = 5 in both strata (Box 3). In this case, the effect of smoking was completely confounded by alcohol, and adjusting for alcohol reduced the effect of smoking to zero. In reality, many associations are only partially confounded, and the effect of smoking may have been reduced after adjustment for alcohol rather than removed. In other cases, confounding may be so extreme that the effect size is reversed after adjustment for the confounding variable — this is called Simpson’s paradox. Why should a confounder not be an intermediate? The last part of the definition of a confounder is that it should not be an intermediate between the exposure and the outcome, that is, the confounder should not be caused by the exposure. In the example, we could postulate that smoking led to drinking and that drinking is what caused the increased risk of dementia. In this case, adjusting for drinking would remove precisely the effect we were trying to see. The effect of smoking on dementia may be entirely mediated through drinking, in which case, adjusting for drinking would remove the effect we are trying to measure. On the other hand, the effect of smoking on dementia may be mediated partially through drinking and partially through other mechanisms, and therefore, adjusting for drinking would remove part of the effect of smoking. We may then speak about the total effect of smoking on dementia, which includes all pathways, and then tease out the direct effect (effect of smoking directly on dementia) or multiple indirect effects (effect of smoking on dementia via drinking or other intermediates). The ultimate solution to confounding In an observational study, we cannot ensure that all potential confounders are identified and accurately measured, and hence there is always the possibility of residual confounding. Some authors have suggested that the choice of a control exposure (which should have no association with the outcome) or a control outcome (which should have no association with the exposure) may be used to shed light on the possibility of residual confounding.2 However, using a randomised controlled trial (RCT) is the only way we can ensure that confounding is handled definitively. This is exemplified by the debate over hormone replacement therapy, where results from over 30 years of data from hundreds of observational studies — collected in different settings and analysed with adjustment for different potential confounders — were overturned by one large RCT.3 Why is the RCT so powerful? By randomly assigning a sufficiently large number of people to two (or more) groups, we achieve an even distribution of all known — and more importantly, unknown — confounders across the trial arms. Any difference in outcome between the two groups is due to the only difference between them: the intervention assigned. Nevertheless, this does not mean that results from all RCTs can be believed; between the time of randomisation (when all potential confounders are evenly balanced) and the time of analysis (when outcomes are measured), there are many opportunities for that even balance of confounders to be upset and we must use our critical appraisal skills to evaluate the validity of the trial.4 Box 1 – Association of smoking and dementia Dementia Risk of outcome Present Absent Smoking 30 70 30% Non-smoking 18 82 18% Box 2 – Association of smoking and dementia stratified by non-drinking and drinking Dementia Risk of outcome Present Absent Non-drinking Smoking 5 45 10% Non-smoking 8 72 10% Drinking Smoking 25 25 50% Non-smoking 10 10 50% Box 3 – Association between drinking and dementia stratified by non-smoking and smoking Dementia Risk of outcome Present Absent Non-smoking Drinking 10 10 50% Non-drinking 8 72 10% Smoking Drinking 25 25 50% Non-drinking 5 45 10%

John R Attia · Michael P Jones · Alexis Hure

A 57-year-old man was treated for schizophrenia with clozapine 900 mg daily over 22 years. His history included epilepsy, hypertension and hypercholesterolaemia, which was treated with clonazepam, clonidine and atorvastatin. Examination showed acuity 6/5 bilaterally, corneal and macular pigmentation (Figure, A, arrow, compared with B, which is normal macula), with subfoveal atrophy and disruption of the photoreceptor-retinal pigment epithelium junction on optical coherence tomography scan ([OCT]; Figure, C compared with D, which is a normal OCT, arrows), and left eye macular dysfunction on multifocal electroretinography ([ERG]; Figure, E compared with F, which is a normal ERG). These changes were similar to previously described clozapine-associated retinopathy.1 Clonazepam is associated with depigmentary retinopathy and normal ERG responses.2 Clonidine and atorvastatin have no documented retinopathy. The patient’s hyperpigmentation may be due to clozapine absorption via the choroid, binding to retinal pigment epithelium and interrupting photoreceptor phagocytosis.3 High dose clozapine warrants ophthalmic follow-up. Figure

Jessica Y Tong · Amy Pai · Peter Heydon · Stephanie H Young

Roll the blinds up …

Eloise Faichney

Mind and body are intimately linked, in health and in disease

Alexander C McFarlane

The answer is predicated on our knowing what the correct treatment is — and we don’t

Jamie E Seymour

A comprehensive approach to the health care of veterans with PTSD is needed

Sarah C McLeay · Wendy M Harvey · Madeline NM Romaniuk · Darrell HG Crawford · David M Colquhoun · Ross McD Young · Miriam Dwyer · John M Gibson · Robyn A O'Sullivan · Graham Cooksley · Christopher R Strakosch · Rachel M Thomson · Joanne Voisey · Bruce R Lawford

Icepacks remain the treatment of choice

Geoffrey K Isbister · Didier J Palmer · Rebecca L Weir · Bart J Currie

Identifying and removing barriers to completing the vaccination course in schools is proving successful

Julia ML Brotherton · Karen L Winch · Lisette Bicknell · Genevieve Chappell · Marion Saville

Acrophobia is a chronic disorder that may have a serious impact on people’s lives

Bruce Arroll · Henry B Wallace · Vicki Mount · Stephen P Humm · Douglas W Kingsford

Back pain is a symptom and not a diagnosis

Lynn D Bardin · Peter King · Chris G Maher

To the Editor:I question that clinicians and the public may be reassured that the evidence underpinning the renewal of the National Cervical Screening Program (NCSP) is sound.1 A fundamental aspect of the sensitivity of a screening test is the definition of the disease of interest that the test seeks to detect. For cancer screening, it is disease that will progress to life-threatening cancer and not the sensitivity to detect disease that only may progress to cancer.2,3 It is a very common but profound error to consider these equivalent,2 particularly when comparing two tests that measure different aspects of the disease process. Overdiagnosis and regression biases are avoided by using the interval cancer method to estimate sensitivity.2,3 The estimates of the sensitivity of human papillomavirus (HPV) testing and cytology, used in the models of the New South Wales group to justify the NCSP renewal policy, were for the detection of cervical intraepithelial neoplasia (CIN) grade 2+ and not for the detection of progressing disease.4 Their approach is fraught because CIN 2 and CIN 3 have different rates of regression and persistence. A higher sensitivity of HPV to detect CIN 2, but lower sensitivity to detect CIN 3 or progressive disease, will produce a lower effectiveness to reduce invasive cervical cancer than cytology, despite a higher sensitivity to detect CIN 2+. There is evidence from the randomised controlled trials that this is the case, even within the regression, persistence but no progression, and progression spectrum of CIN 3. The results of the only randomised trial of the implementation of HPV testing in a screening program, published in 2013,2 found the sensitivity of HPV testing (87%) to detect disease that progresses to invasive cervical cancer to be lower than cytology screening (93%). The authors concluded that “sensitivity of HPV testing was similar to that of Pap testing but caused more overdiagnosis. Therefore, implementation of HPV testing needs to be reconsidered especially in countries with well organised programmes”. This suggests that it is mathematically impossible for HPV testing to provide greater protection from invasive cervical cancer than cytology. Assuming participation of 80%, the renewal program will increase the incidence of cervical cancer by about 39%, and the unit of economic effectiveness will be dollars saved per life prematurely lost. From the perspective of public health medicine, it would be professionally negligent not to estimate the effect of moving to 5-yearly HPV testing using the Finnish estimates of the sensitivity of HPV testing and cytology, but instead rely only on estimates with major regression and overdiagnosis bias.4

Brian Cox

In reply

Jonathan Carter · Ian Hammond · Megan Smith

Dr Jane Cooper was the RACGP’s GP of the Year in 2016. She’s an advocate for early intervention and embedding deeply into the community she serves

Cate Swannell

Professor Chris Stapelberg has been named as the Joint Chair in Mental Health for Bond University and Gold Coast University Hospital. Professor Stapelberg is a senior staff specialist in psychiatry, working at the Gold Coast University Hospital as a consultation liaison psychiatrist. He is the Mental Health and Specialist Services Director of Research, chair of the Gold Coast Hospital Mental Health and Specialist Services Research Committee and until recently was deputy chair of the Gold Coast Hospital and Health Service Research Council. Professor Stapelberg was previously the Clinical Lead in Mental Health at the Griffith University School of Medicine, where he was involved with teaching, curriculum development, and examinations and received a number of teaching awards. For the past 8 years he has been researching major depression and has also undertaken work mapping the physiological network of relationships in depression and biomarkers in the context of major depression, notably heart rate variability. Professor Stapelberg completed a PhD on the impact of depression on heart rate variability in people with, and without, coronary heart disease. He is now the principal investigator, or co-investigator, on a number of research projects in this area. Since 2013 he has been an Invited Expert on depression for the Global Burden Of Disease Project with the World Health Organization. https://bond.edu.au/news/49056/bond-health-sciences-medicine-appoints-joint-chair-mental-health?context=hsm Dr Ruth McNair, a GP and Honorary Associate Professor at the University of Melbourne’s Department of General Practice, has been inducted onto the Victorian Honour Roll of Women. Dr McNair has made a lasting contribution to the general health and quality of care for countless gay, bisexual, transgender and intersex (LGBTI) individuals, families, partners and allies in the local community. She has also worked with various marginalised populations including Aboriginal communities and women prisoners. In 2009, she helped to establish Northside Clinic in North Fitzroy which has a focus on addressing the general health needs of Melbourne’s LGBTI community. Dr McNair is currently the Co-chair of the Victorian LGBTI Health and Human Services Working Group and a member of the LGBTI Taskforce. She is also Chairperson of the Gay and Lesbian Foundation of Australia, Founding Member and previous convener of the Australian Lesbian Medical Association and Founding Member of Rainbow Families. http://www.vic.gov.au/women/women-s-leadership/victorian-honour-roll-of-women/victorian-honour-roll-details-page.html?honour-roll_id=22 Dr Marguerite Evans-Galea, from the Murdoch Children’s Research Institute and the University of Melbourne, has been inducted onto the Victorian Honour Roll of Women. Over the past 15 years, Dr Evans-Galea has led international collaborations to better understand disease mechanism and developed novel therapies and biomarkers for repeat-associated neurodegenerative diseases. The contributions she has made in gene and cell therapy and in Friedreich ataxia, a condition affecting children that results in progressive deterioration in motor function, have been recognised with national and international awards. Through the Australasian Gene and Cell Therapy Society, she has also fostered greater ties between leading investigators in gene therapy and stem cell research, many of which are based in Victoria. Dr Evans-Galea was recently appointed as the inaugural Executive Director of the Industry Mentoring Network in Science, Technology, Engineering, Mathematics and Medicine with the Australian Academy of Technological Sciences and Engineering. http://www.vic.gov.au/women/women-s-leadership/victorian-honour-roll-of-women/victorian-honour-roll-details-page.html?honour-roll_id=31 Dr Christine Tippett, AM, founder and director of Maternal-Fetal Medicine at the Monash Medical Centre and senior lecturer in the Department of Obstetrics and Gynaecology at Monash University, has been inducted onto the Victorian Honour Roll of Women. Specialising in high risk obstetrics and gynaecology, for 45 years Dr Tippett has made an “outstanding contribution to medicine in Victoria, saving the lives of women and newborns and improving the quality of care Australian women receive during pregnancy”. She has delivered more than 10 000 babies throughout her career and has been instrumental in advocating for change in the field of obstetrics and gynaecology, helping to create a safer environment for both mothers and babies. She won the RANZCOG Gold Medal in 1984 and became the College’s first female president in 2006. http://www.vic.gov.au/women/women-s-leadership/victorian-honour-roll-of-women/victorian-honour-roll-details-page.html?honour-roll_id=20 Dr Ray Moynihan, from Bond University, has won a 4-year fellowship from the NHMRC to investigate the problem of overdiagnosis – which happens when someone is diagnosed with a disease that won’t actually harm them. A Senior Research Fellow at Bond’s Centre for Research in Evidence-Based practice, who obtained his PhD in 2015, Dr Moynihan’s most recent research examined the example of osteoporosis – where the formal definition automatically labels many healthy older women who will never experience a fracture as “diseased”. Under the supervision of Bond University’s Professor Paul Glasziou, Dr Moynihan plans to investigate how and why so many disease definitions are expanding, in order to better respond to the problem of overdiagnosis. https://bond.edu.au/news/49081/expanding-disease-definitions-under-scientific-scrutiny?context=hsm

Cate Swannell

This calendar will be updated each month. If you have an event you would like to add, please include relevant details in an email to cswannell@mja.com.au. The full version of the calendar is available online at www.mja.com.au April 1-2 iDEA17: Global problems, Local Solutions, Melbourne, VIC 2-5 Perinatal Society of Australia and New Zealand 20th Annual Congress 2017, Canberra, ACT 3 Paediatric Anaesthesia Crisis Management Course (PACMaC), Wellington, NZ 3-7 15th World Congress on Public Health: Voices, Vision, Action, Melbourne, VIC 4 CICM Fellow Education workshop, WA 4-7 LIME Connection VII: The future of Indigenous Health Education: Leadership, Collaboration, Curriculum, Melbourne, VIC 7 Nursing Emergency External Trauma Program, Melbourne, VIC 7-8 2nd International Lymphoma Radiation Oncology Group Educational Conference: Radiotherapy in Modern Lymphoma Management, Melbourne, VIC 7-9 Spine Society of Australia 28th ASM 2017, Hobart, TAS 8-9 Neuromodulation Society of Australia and New Zealand 12th Annual Scientific Meeting, Adelaide, SA 8-9 Rural Health West Annual Conference: Embracing the Unexpected – The Unpredictable World of Rural Health Care, Perth, WA 8-10 11th Annual Update in Paediatric Emergencies 2017, Noosa, QLD 9-12 2017 Australian Pain Society 37th ASM, Adelaide, SA 21-23 Trauma 2017 Conference: Bridging the Gaps in Trauma Care, Melbourne, VIC 21-23 Australian and New Zealand Society of Nuclear Medicine 47th ASM 2017, Hobart, TAS 22-23 Focused Cardiac Ultrasound/ECHO Workshop, Melbourne, VIC 26 ANZCA Approved Anaphylaxis & CICO Emergency Response Workshop, Frankston, VIC 27-28 Australian Telehealth Conference, Melbourne, VIC 28 Anaesthetic Emergency Responses Workshop (ALS/CICO), Sunshine, VIC 29-30 iHeartScan, Melbourne, VIC 29 Apr-2 May 14th World Rural Health Conference 2017, Cairns, QLD 30 Apr-4 May Royal Australian and New Zealand College of Psychiatrists Conference 2017, Adelaide, SA May 2-5 New Zealand Society for the Study of Diabetes AGM 2017, Dunedin, NZ 4 Choosing Wisely Australia National Meeting 2017, Melbourne, VIC 5 Vitiligo Master Class, Sydney, NSW 5-7 QRME Ltd OSCE Intensive Examination & Communication Workshop: Helps Candidates Focus on Their Communication Skill, Toowoomba, QLD 6 Emergency Radiology Course, Sydney, NSW 6-7 21st ASM of the Australasian Musculoskeletal Imaging Group, Melbourne, VIC 6-9 Australasian College of Dermatologists ASM, Sydney, NSW 7-9 Transplantation Society of Australia and New Zealand 35th ASM 2017, Brisbane, QLD 8 Focused Cardiac Ultrasound TTE, Melbourne, VIC 8 CICM Fellow Education Workshop, VIC 9 CICM Fellow Education Workshop, SA 8-10 RACP Congress 2017: Bringing Specialists Together, Sharing Knowledge, Building Skills, Melbourne, VIC 8-12 Royal Australasian College of Surgeons 86th Annual Scientific Congress 2017, Adelaide, SA 9-12 Australian and New Zealand Association of Neurologists 2017, Gold Coast, QLD 10-12 Airway Management SIG Meeting 2017, Brisbane, QLD 10-12 Immunotherapy@Brisbane 2017, South Brisbane, QLD 10-12 Australian and New Zealand Society for Geriatric Medicine ASM 2017, Rotorua, NZ 12 6th Biennial Update in Paediatric Respiratory Medicine, Sydney, NSW 12-13 Royal Australian and New Zealand Collage of Ophthalmologists New Zealand Branch ASM 2017, Waitangi, NZ 12-16 Australian and New Zealand College of Anaesthetists ASM 2017, Brisbane, QLD 15-17 Australian and New Zealand Addiction Conference, Gold Coast, QLD 18-21 Rural Health West’s Rural and Remote Retrieval Conference, Karijini National Park, WA 19-20 Australian Symposium Organised by The Falk Foundation: Mucosal Microbiome and Mucosal or Systemic Dysfunction: Mechanisms, Clinical Manifestations and Interventions, Brisbane, QLD 19-21 General Practice Conference and Exhibition, Sydney, NSW 20-21 Focused Cardiac Ultrasound/ECHO Workshop, Sydney, NSW 20-21 Neurorad 2017, Melbourne, VIC 20-23 Australasian Rheumatology Association and New Zealand Rheumatology Association Joint Scientific Meeting 2017, Auckland, NZ 22-23 Australian and New Zealand Disaster and Emergency Management Conference 2017, Gold Coast, QLD 24 FUSE Vascular, Melbourne, VIC 26-28 College of Intensive Care Medicine of Australia and New Zealand, 2017 ASM: A Gut Reaction: ICU Gastroenterology From Beginning to End, Sydney, NSW 26-28 Australian Medical Association National Conference, Melbourne, VIC 28-31 Speech Pathology Australia National Conference 2017, Sydney, NSW 29-30 New Anaesthetic Registrars Crisis Management (NARCM) Course, Wellington, NZ June 1-2 NSW branch of Australian Resuscitation Council and Take Heart: Resus @ The Park, Sydney, NSW 2-4 41st ASM of the Australasian Division of the International Academy of Pathology, Darling Harbour, NSW 3 Epworth Healthcare Cancer Services Clinical Institute Symposium: Recent Advances In Cancer Therapies and Cancer Survivorship, Melbourne, VIC 3-4 Focused Cardiac Ultrasound/ECHO Workshop, Melbourne, VIC 3-4 EMCORE 2017, Melbourne, VIC 4-8 19th International Symposium on Recent Advances in Ottis Media, Gold Coast, QLD 7 Lung Ultrasound, Melbourne, VIC 12-13 International Summit on Vaccines and Immunology, Brisbane, QLD 15-17 Cancer Nurses Society of Australia Annual Congress, Adelaide, SA 16 Epworth Healthcare Second Musculoskeletal Clinical Institute Symposium: The Shoulder, Melbourne, VIC 19-21 Renal Society of Australasia Annual Conference 2017, Sydney, NSW 20-22 Tinnitus 2017, Melbourne 2017 21 ANZCA Approved Anaphylaxis & CICO Emergency Response Workshop, Frankston, VIC 22-25 Australian Society of Aesthetic Plastic Surgery Non-surgical Symposium 2017, Gold Coast, QLD 23 Crisis Management in Obstetric Anaesthesia and Neonatal Resuscitation, Sunshine, VIC 24-25 Focused Cardiac Ultrasound/ECHO Workshop, Surfers Paradise, QLD 26-27 2017 No More Harm National Conference, Brisbane, QLD 28-30 CSANZ New Zealand ASM 2017, Hamilton, NZ 29 Introduction to Research Methods, Melbourne, VIC 30 Introduction to Biostatistics, Melbourne, VIC July 1-2 iHeartScan, Melbourne, VIC 6-9 Australia and New Zealand Society of Neuroradiology ASM 2017, Darwin, NT 7-8 2017 Rural SIG Meeting, Broome, WA 11-13 Interventional Radiology Society of Australasia ASM 2017, Port Douglas, QLD 13-15 RANZCO Paediatric Special Interest Group Scientific Meeting, Sydney, NSW 17-19 12th Asian Obesity Specialists and Endocrinologists Annual Meeting, Melbourne, VIC 17-19 9th World Congress on BA/BE Studies and Biowaivers, Melbourne, VIC 20 CICM Fellow Education workshop, NSW 20-22 Effective Management of Anaesthetic Crises (EMAC), Melbourne, VIC 20-22 Diabetes Asia Pacific 2017: 12th Asia Pacific Diabetes Conference and Expo, Melbourne, VIC 22 Medical Imaging Anatomy Course, Melbourne VIC 22-23 Emergency Skills Ultrasound, Melbourne, VIC 22-23 General Practice Conference and Exhibition, Perth, WA 23-26 Cardiac Thoracic Vascular and Perfusion SIG Meeting, Queenstown, NZ 23 Focused Cardiac Ultrasound TOE, Queenstown, NZ 23 Focused Cardiac Ultrasound TTE, Queenstown, NZ 23 Lung Ultrasound, Queenstown, NZ 24-25 17th International Conference and Exhibition on Nanomedicine and Nanotechnology in Health Care, Brisbane, QLD 24-26 8th World Conference on Pharmacology and Toxicology, 10th Asia-Pacific Pharma Congress, Melbourne, VIC 24-26 World Congress on Nursing Care 2017, Melbourne, VIC 24-28 Missioncraft 2017: Leadership in Disaster Relief, Melbourne, VIC 26-28 Effective Management of Anaesthetic Crises (EMAC) Course, Wellington, NZ 26-29 Australasian College for Emergency Medicine Winter Symposium, Rowland Flat, SA 26-29 APCCN 2017 – Asia Pacific Conference on Clinical Nutrition, Adelaide, SA 27-28 The Australian Winter School Conference: Connecting the alcohol and drugs sector, Brisbane, QLD 27-30 RNZCGP Conference for General Practice and Quality Symposium, Dunedin, NZ 28 QRME Ltd Mental Health Skills Training: equip participants with the knowledge and skills to effectively assess and manage patients presenting with mental health concerns, Toowoomba, QLD 28-29 Lancet Summit: COPD and lung cancer, Perth, WA 31 Jul-2 Aug World Congress on Microbiology and Infectious Diseases, Melbourne, VIC 31 Jul-2 Aug International Meeting on Nursing Research and Evidence-based Practice, Melbourne, VIC 31 Jul-2 Aug Pharmaceutics Meeting 2017 – Global experts meeting on pharmaceutics and drug delivery systems, Melbourne, VIC August 4 Anaesthetic Emergency Responses Workshop (ALS + CICO), Sunshine, VIC 9 Peri-Arrest, Melbourne, VIC 11-13 ACD Rural Dermatology Meeting, Broome, WA 16 ANZCA Approved Anaphylaxis & CICO Emergency Response Workshop, Frankston, VIC 16 FUSE Vascular, Melbourne, VIC 16-19 NZDSI Annual Conference, Queenstown, NZ 19-20 iHeartScan Advanced, Melbourne, VIC 21-25 CT-Acute Medical and Surgical Interpretation 2017, Queenstown, NZ 21-27 Be Medicinewise Week 24 Paediatric Anaesthesia Crisis Management Course (PACMaC), Wellington, NZ 26-27 Focused Cardiac Ultrasound/ECHO Workshop, Melbourne, VIC 28-30 DFTB17: Making a difference, Brisbane, QLD 31 Aug-2 Sep 5th World Congress on Controversies, Debates and Consensus in Bone, Muscle and Joint Diseases, Gold Coast, QLD September 1 Epworth HealthCare Eighth Obstetrics & Gynaecology Clinical Institute Symposium, Melbourne, VIC 1 QRME Ltd Cultural Safety Training: Developing positive, respectful relationships with Aboriginal and Torres Strait Islander people, create a culturally safe practice, administer the PIP – Indigenous Health Incentive, Toowoomba, QLD 1-2 Australia and New Zealand Academy for Eating Disorders, Darling Harbour, NSW 1-3 Managing Obstetric Emergencies & Trauma (MOET) Course, Wellington, NZ 1-3 General Practice Conference and Exhibition, Brisbane, QLD 2-3 QRME Ltd Advanced Lift Support: build participants’ knowledge, skills and confidence when responding to rural general practice emergencies, Toowoomba, QLD 6-7 6th Annual International Emergency Care Conference, Melbourne, VIC 6-8 Effective Management of Anaesthetic Crises (EMAC) Course, Wellington, NZ 6-8 2017 Australian Palliative Care Conference: Connection with community, Adelaide, SA 8 The Alfred Emergency and Trauma Centre Resuscitation Update, Melbourne, VIC 8-10 Joint Neuroanaesthesia and Trauma SIG Meeting, Byron Bay, NSW 9-10 ANZCA/ASA SA NT Burnell Jose Visiting Professionals ASM, Rowland Flat, SA 13-14 Big Data and Analytics Innovation Summit: Maximise the Potential of Your Big Data Initiatives, Sydney, NSW 13-15 28th Annual Conference of the Australasian Society of Clinical Immunology and Allergy, Auckland, NZ 14 RUOK? Day 14 CICM Fellow Education workshop, TAS 14-16 Australasian Doctors’ Health Conference, Sydney, NSW 14-17 Neuro-Ophthalmology Society of Australia 33rd Clinical and Scientific Meeting and NeuroVision Training Weekend, Sydney, NSW 15 Crisis Management in Obstetric Anaesthesia and Neonatal Resuscitation, Sunshine, VIC 16 Epworth Healthcare Perioperative Medicine Symposium, Melbourne, VIC 16-17 ANZAAG Symposium, Auckland, NZ 20-22 6th APAC Forum: Lead the change you want to see, Gold Coast, QLD 23 Trauma Radiology Course, Brisbane, QLD 27-29 Joint 2017 ACHSM/ACHS Asia-Pacific Congress, Sydney, NSW October 2-4 16th Global Pathologists Annual Meeting, Melbourne, VIC 4 FUSE Vascular, Melbourne, VIC 4-6 Global Alcohol Policy Conference, Melbourne, VIC 7-10 ASA National Scientific Congress 2017, Perth, WA 8-12 AOA 77th ASM and AGM, Adelaide, SA 11-13 42nd Australian and New Zealand ASM in Intensive Care and the 23rd Annual Paediatric and Neonatal Intensive Care Conference: ICU: Thinking outside the flags, Gold Coast, QLD 12-14 EMAC (Effective Management of Anaesthetic Crises) Course, Melbourne, VIC 16 Focused Cardiac Ultrasound TTE, Melbourne, VIC 16-18 3rd International Conference on Antimicrobial Agents and Chemotherapy, Melbourne, VIC 18-21 9th World Congress of Melanoma and 14th International Congress of the Society for Melanoma Research, Brisbane, QLD 20 Crisis Management in Obstetric Anaesthesia and Neonatal Resuscitation, Sunshine, VIC 20-22 QRME Ltd OSCE Intensive Examination & Communication Workshop: helps candidates focus on their communication skill, Toowoomba, QLD 21-22 Focused Cardiac Ultrasound/ECHO Workshop, Sydney, NSW 24-27 Australian Association of Practice Managers National Conference, Perth, WA 26-28 GP17 RACGP Annual conference, Sydney, NSW 26-28 SPANZA 2017 Conference, Perth, WA 28 Epworth HealthCare Seventh Cardiac Sciences Clinical Institute Symposium, Melbourne, VIC 28 Oct-1 Nov 49th RANZCO Annual Scientific Congress, Perth, WA 29 Oct-1 Nov RANZCOG Annual Scientific Meeting, Auckland, NZ November 1-3 10th Health Services and Policy Research Conference, Gold Coast, QLD 1-3 Effective Management of Anaesthetic Crises (EMAC) Course, Wellington, NZ 2-4 Perioperative Medicine SIG Congress 2017 8-11 NZ Anaesthesia ASM 2017, Rotorua, NZ 10 Anaesthetic Emergency Responses Workshop (ALS + CICO), Sunshine, VIC 10-12 General Practice Conference and Exhibition, Melbourne, VIC 13-19 Antibiotic Awareness Week 15 Focused Cardiac Ultrasound TOE, Melbourne, VIC 15-17 Hospital in the Home Society of Australasia ASM, Melbourne, VIC 16-18 EMAC (Effective Management of Anaesthetic Crises) course, Melbourne, VIC 17-19 National Histology Conference, Hobart, TAS 18-19 iHeartScan, Melbourne, VIC 19-23 Australasian College for Emergency Medicine, 34th ASM, Sydney, NSW (provisional dates) 20-22 9th International Conference on Immunopharmacology and Immunotoxicology, Melbourne, VIC 20-22 Psychiatry and Mental Health 2017, Melbourne, VIC 20-24 Psychiatry Update 2017, Christchurch, NZ 21-23 Effective Management of Anaesthetic Crises (EMAC), Melbourne, VIC 23-26 Asian Pacific Society of Respirology Congress 2017, Sydney, NSW 26-29 APCCN 2017 – Asia Pacific Conference on Clinical Nutrition, Adelaide, SA 27-28 New Anaesthetic Registrars Crisis Management (NARCM) Course, Wellington, NZ 29-30 Innovate Alzheimers – Alzheimers and Dementia, Brisbane, QLD 29-30 International summit on medical, pharma and drug studies, Brisbane, QLD December 1-2 International summit on infectious diseases and antibiotics, Brisbane, QLD 2-3 Focused Cardiac Ultrasound/ECHO Workshop, Melbourne, VIC 3-6 Australasian Neuroscience Society annual meeting, Sydney, NSW 7-12 Melbourne Neuro and Orthopaedic MRI Course, Melbourne, VIC February 2018 9-10 4th International 4 Corners of Cardiology Meeting, Melbourne, VIC 23-24 PICET Obstetric Intensive Care Symposium, Adelaide, SA March 2-4 Pathology Update 2018, Sydney, NSW 8-11 APSCVIR 2018, Auckland, NZ April 11-13 2nd International Selection in the Health Professions Conference, Melbourne, VIC May 7-11 Royal Australasian College of Surgeons Annual Scientific Congress 2018 with the ANZ College of Anaesthetists, Sydney, NSW 18-22 Australasian College of Dermatologists ASM, Gold Coast, QLD October 6-9 ASA National Scientific Congress 2018, Adelaide, SA November 7-10 New Zealand Anaesthesia Annual Scientific Meeting 2018, Auckland, NZ 18-22 Australasian College for Emergency Medicine, 35th ASM, Perth, WA November 2021 10-13 XIII International Congress of Dermatology, Melbourne, VIC December TBA FIGO World Congress of Gynaecology and Obstetrics, Sydney, NSW

Cate Swannell