Volume 206 Issue 8

Resource distribution in stroke care must be rational and evidence-based, not driven by media coverage

Yun Tae Hwang · Yash Gawarikar

If regenerative neurology restores function, it will meet a huge unmet need and change dogma

Simon A Koblar · Anjali Nagpal · Fong Chan Choy · Monica Anne Hamilton-Bruce · Susan L Hillier

Equity of access is particularly concerning for minor stroke

Emma C Finch · Michele M Foster · Jennifer Fleming · Philip D Aitken · Ian Williams · Tegan Cruwys · Linda Worrall

We should aim at improving the care of dying patients

Ezekiel Emanuel

A 74-year-old right-handed man with homonymous hemianopia from an occipital stroke presented with an abrupt behaviour change

Takeshi Kondo · Kazuhiko Terada

The key to finding solutions for brain disorders is cooperation and collaboration from the laboratory to the clinic

Kay L Double · Linda J Richards

Effective strategies for improving outcomes require efficient triage and interdisciplinary cooperation

Matthew C Kiernan

Appropriate risk adjustment of stroke outcome data is needed for assessing and ensuring quality of care

Graeme J Hankey

Comparisons of hospital mortality rates for stroke are critically affected by the statistical approach employed

Dominique A Cadilhac · Monique F Kilkenny · Christopher R Levi · Natasha A Lannin · Amanda G Thrift · Joosup Kim · Brenda Grabsch · Leonid Churilov · Helen M Dewey · Kelvin Hill · Steven G Faux · Rohan Grimley · Helen Castley · Peter J Hand · Andrew Wong · Geoffrey K Herkes · Melissa Gill · Douglas Crompton · Sandy Middleton · Geoffrey A Donnan · Craig S Anderson

Measuring changes in prevalence is important given the possibility of future Zika virus-related disease

Michele Hansen · Paul K Armstrong · Carol Bower · Gareth S Baynam

Recent evolution in the clinical, pathological and genetic understanding of MND is progressively unmasking the multifactorial nature of this complex condition

Thanuja Dharmadasa · Robert D Henderson · Paul S Talman · Richard AL Macdonell · Susan Mathers · David W Schultz · Merrillee Needham · Margaret Zoing · Steve Vucic · Matthew C Kiernan

The brain–computer interface is an exciting advance in neuroscience and engineering

Jeffrey V Rosenfeld · Yan Tat Wong

To the Editor:In her MJA article, Murphy poses the question “who are we talking about when we discuss voluntary euthanasia laws?” and presents two hypothetical scenarios.1 The South Australian Voluntary Euthanasia Bill 2016 defines an eligible person as a competent adult, subject to unbearable and hopeless suffering, with no impaired decision-making capacity, and who has lived in the state for no less than 6 months.2 The degree to which the suffering is unbearable is determined subjectively. A person’s suffering is considered hopeless if medical treatment cannot reduce or relieve the suffering to a level that is bearable to the person. The nature, availability and potential effectiveness of such treatment are determined objectively under the provisions of the Bill. As Murphy observes: “Every person’s story is different and we must be careful not to lump them together”.1 It is also true that aged care and mental health systems need much greater government investment. However, this alone will be unable to deal with the highly particularised needs of people whose lives have become unbearable despite the best medical or palliative care. The 2016 Victorian inquiry into end of life choices stated: “Under the existing legal framework, Victorians with serious and incurable conditions and irremediable suffering are exposed to the possibility of a traumatic death. Some are driven to suicide.”3 The inquiry recommended a legal framework to allow assisted dying for the small number of people who seek help to end their suffering. Such legal reform would surely provide great reassurance by ending the fear of enforced protracted suffering, which leads to pre-emptive and often violent suicides. Examples of the tragic circumstances triggering these actions were compellingly recounted by Coroner John Olle before the Victorian inquiry4 and alluded to in Murphy’s own account of reading “emotionally draining” case files of suicides in nursing homes. The legal status quo is an indictment of a civilised society.

Julia M Anaf

In reply

Briony J Murphy

To the Editor:We commend Kahn and colleagues1 for publishing their data on the pre-hospital use of fibrinolysis and showing that the outcomes were similar to those treated by primary percutaneous coronary intervention (PCI). However, we noted that the median first medical contact to device time for those receiving primary PCI was 130 minutes, and indeed > 75% of patients had longer than the 90 minutes recommended in the recent National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand guidelines.2 Although there is still some uncertainty about acceptable time delays to PCI, these data suggest that even more individuals should be receiving pre-hospital thrombolysis. As an alternative, perhaps patients should be randomised in clinical trials that address the relative usefulness of these two reperfusion strategies in circumstances of likely moderately prolonged times to primary PCI. Moreover, among those patients undergoing pharmaco-invasive PCI, the dose of the fibrinolytic drugs used requires definition.3

John K French · Derek P Chew · Richard W Harper · Philip EG Aylward

In reply

Arshad A Khan · Peter J Fletcher · Andrew J Boyle

To the Editor:Acute stroke management has undergone major transformations with the advent of endovascular thrombectomy, but there remains a large gap in care between metropolitan and rural Australia. While metropolitan stroke centres are currently redesigning their services to expedite intervention for patients eligible for endovascular thrombectomy, rural and remote areas are still lagging behind with basic stroke therapies. Alteplase therapy for acute stroke within 4.5 hours remains the bedrock of treatment. Nevertheless, presenting to a hospital that has the capability to facilitate this treatment is not as simple for a rural patient as for a metropolitan patient. Distance and isolation are major factors in preventing access to treatment, as is lack of local expertise. In addition, there is a paucity of neurologists working in rural Australia. Where Melbourne and Sydney boast one neurologist for every 25 000 persons, rural Australia ranges from one in 100 000–200 000 people (Costello, C. Australian and New Zealand Association of Neurologists Workforce Survey. Sydney: ANZAN; 2016 [unpublished internal report]). There are rural physicians who are skilled in the management of acute stroke, but there remain barriers and reluctance to use thrombolysis within this group.1 The impact of stroke also significantly burdens the rural Indigenous community. In the Northern Territory, the Indigenous population have a three times higher incidence (307 per 100 000 people) of stroke, a younger age of onset (10 years earlier), higher case fatality, higher stroke recurrence and higher cost of lifetime stroke compared with non-Indigenous and metropolitan patients.2,3 Due to remoteness and delays in transfer, Indigenous people often miss the opportunity for acute therapy. Telestroke services are currently being used in certain parts of regional Australia; they are an effective, safe and efficient method of bringing the metropolitan neurologist to the rural patient’s bedside.4 However, more resources must be invested to make this a service that covers all corners of the country. In addition, it is necessary to implement better recruitment strategies for neurologists to rural centres and stroke-specific public health campaigns that are culturally appropriate, and to increase funding for research to design innovative and creative ways to provide comprehensive care to remote patients. Urgent action is required now; otherwise, an isolated part of our country and community will only face greater challenges over time.

Prashanth Ramachandran · James Burrow

Tania Farrar is an advanced trainee in neurology, part of the first graduating class at the University of Notre Dame (Sydney), and a former Intern of the Year

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 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 24-25 1st Australasian Diagnostic Error in Medicine Conference, 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 11-14 Australian and New Zealand Association for Health Professional Educators 2017 Conference, Adelaide, SA 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 7-8 ANZICS 2017 Safety and Quality Conference: The Deteriorating Patient, Sydney, NSW 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 17-18 Colorectal Cancer Conference 2017, Melbourne, VIC 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 30 Aug-2 Sep 18th Asia-Pacific Prostate Cancer Conference, Melbourne, VIC 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

Cate Swannell