Volume 206 Issue 9

Advance care directives can enable Aboriginal people to fulfil their end-of-life wishes to die in their community

Eswaran Waran · Sharon Wallace · Jonathan Dodson-Jauncey

Generalist training may be a solution for responding to future population health needs

Judith N Hudson · Kathryn M Weston · Elizabeth A Farmer

The Health Care Home is a central component of our national health reforms, and refining the model for broader implementation is essential

Claire L Jackson · Steven J Hambleton

High immunisation rates in Australia mean that the threat of disease transmission posed by vaccine refusal is low — policy responses should be proportionate

Frank H Beard · Julie Leask · Peter B McIntyre

A case of serious injury playing Pokémon GO

Maria Franchina · Swati Sinkar · Boon Ham · Geoffrey C Lam

A 51-year-old man presented with a 3-year history of recurrent upper eyelid haematomas

Cecily J Forsyth · Campbell R Tiley

A 54-year-old man, formerly a smoker, presented with a 6-year history of chronic cough and exertional breathlessness without previous respiratory illnesses

Elie Matar · Anthony Frankel · Lucinda Katharine McCowan Blake · Elizabeth J Silverstone · Anthony R Johnson · Deborah H Yates

Still a valuable component of the physical exam

Thomas Millington Goodsall · Patrick Flynn · John R Attia

A doctor puts emotions aside in an emergency, but dissociation does not help when the illness is in the family

Ruth A Stewart

Burns are a specific health burden, but understanding the detail is vital to finding solutions

Roy M Kimble · Bronwyn R Griffin

The findings of the National Eye Health Survey are encouraging, but also identify areas for improvement

Paul Mitchell

Rates of burn injuries are higher for Indigenous children than for non-Indigenous Australian children

Holger Möller · Lara Harvey · Kathleen Falster · Rebecca Ivers · Kathleen F Clapham · Louisa Jorm

Focus on glycaemic control from diagnosis onwards is needed to reduce the risk of severe retinopathy

Mary White · Matthew A Sabin · Costan G Magnussen · Michele A O'Connell · Peter G Colman · Fergus Cameron

A carefully integrated diabetic retinopathy screening service is needed, particularly in remote areas, to improve adherence rates

Joshua Foreman · Stuart Keel · Jing Xie · Peter Van Wijngaarden · Hugh R Taylor · Mohamed Dirani

? Cognitive biases in decision making may make it difficult for clinicians to reconcile evidence of overuse with highly ingrained prior beliefs and intuition

Ian A Scott · Jason Soon · Adam G Elshaug · Robyn Lindner

To the Editor:Advance care planning (ACP) promotes conversations about future health care, in case a person should lose capacity for decision making. Advance care directives (ACDs) provide written documentation of these conversations. Yet, although the Australian Medical Association advocates ACP within routine clinical practice,1 ACD completion rates remain low.2 While recognising numerous barriers to ACP, including patient, practitioner and health care system factors,3 a dedicated ACP Medicare Benefits Schedule (MBS) item number was mentioned in a number of general discussions at the 2016 Advance Care Planning Australia national conference (Melbourne, 15–17 November) as a potential incentive to increase the use of ACDs in primary care. In general, we support this recommendation. Health economics tells us that where there is a shortage of a specific service, as could be argued for ACP, the supply of this service will increase under fee-for-service payment.4 Patients are less knowledgeable about prices, services and associated benefit than providers; however, the existence of an agency relationship5 (where the patient assigns decisional authority on the basis that they have less information) between general practitioners and patients would facilitate ACDs from which patients are most likely to benefit. On the other hand, there is some risk that financial incentives will motivate GPs to do more than is optimal or desired, especially if the service is priced above standard consultation fees. There is also an opportunity cost; if GPs are providing more ACP services they will have less time to provide other primary care services. However, the risk of financial incentives may be mitigated by the non-financial barriers to ACP (fear or reluctance of patients, insufficient GP skills or organisational factors). Therefore, in designing policies to increase uptake, especially where financial incentives are the driver, a multifaceted approach should be considered. Service reimbursement mechanisms and potential barriers should also be balanced against maintenance of ACP values such as patient autonomy and informed decision making. As a starting point, a two-tiered MBS item number could be beneficial, the first item billable for initiation of ACP and the second used for revisitation of ACDs after a given time period (eg, annual review). Subsequent review of policy responses, including patient and medical practitioner input, will be needed to ensure appropriate directions surrounding MBS billing. Further accompanying strategies may be required to address non-financial barriers to ACP uptake.

Amanda Pereira-Salgado · Jennifer J Watts

To the Editor:The well researched narrative review by Bourke and colleagues1 offers a comprehensive overview of immune-related adverse events (irAEs) in cancer immunotherapy and their management. However, care needs to be taken in adopting too broad an approach, particularly in relation to dermatological irAEs. In the article, “rash” is described as an irAE. However, a rash is a clinical sign, not a diagnosis. The cutaneous irAEs reported in association with immune checkpoint inhibitor therapy span a spectrum of dermatoses including (but not limited to) vitiligo, eczema, lichenoid reactions, morbilliform eruptions, prurigo nodularis, bullous pemphigoid, papulopustular eruptions, rosacea, and cutaneous fungal, bacterial and viral infections.2,3 Categorising every cutaneous irAE as a rash precludes patients from obtaining an accurate diagnosis, which in turn encumbers treatment. Topical corticosteroids are a reasonable first-line treatment option for most pathologies (unless the cutaneous irAE is an infection or papulopustular eruption). However, there is a range of corticosteroid molecules, potencies and vehicles, as well as off-formulary preparations available,4 and physicians should be familiar with this class of drugs before prescribing them. Where accurate diagnosis of a cutaneous irAE becomes particularly important is when topical corticosteroids fail. Systemic corticosteroids, while helpful in containing an acute disease process, are seldom the second-line treatment employed by dermatologists. Dermatologists have an arsenal of topical, physical and systemic therapies at their disposal, and the choice of second-line treatment is determined according to diagnosis. We would therefore offer that a multidisciplinary approach is important in the management of the cutaneous toxicities of the new generation of oncological treatments; not only the moderate and severe as suggested, but also the mild and life-threatening. We commend the rapid rate at which our colleagues in medical oncology have become versed in the fundamentals of dermatological care and recognise only too well the limitations in access to dermatology, even in many of the larger teaching hospitals across Australia.5 However, in many respects, this new era of immunotherapy is uncharted territory, and managing the cutaneous toxicities of these medications necessitates an appreciation of the nuances of managing skin disease.

Rose Liu · Pablo Fernandez-Peñas · Deshan F Sebaratnam

To the Editor:With reference to Batterham and colleagues,1 we applaud the call to better align research funding to disease burden. We also address this shortfall in the leading killer: cardiovascular disease (CVD). The federal government deserves praise for establishing the Medical Research Future Fund (MRFF), doubling funding by 2023. This augurs well for the future, but right now, we face an interregnum while the MRFF builds and the National Health and Medical Research Council funding flatlines. Every year, CVD claims the lives of 45 093 Australians,1 accounting for more than one in three deaths. The direct cost of caring for people with CVD in 2008–09 was $7.7 billion per year (or 12% of the total health budget),2 making it the costliest disease group of all. With the current budget at over $120 billion per annum,3 and assuming that CVD continues to cost 10–12% of the health budget, it is likely that the current cost is well over $12 billion per annum.3 The most recent data show that CVD deaths increased for the first time in 4 decades in men aged 55–64 years,3 an increase associated with the rising rates of obesity and diabetes.3 This reflects the unanswered questions related to heart health, which are ripe for exploration. Meanwhile CVD research is funded substantially less than the equivalent disease burden of cancer, receiving about 13.5% — cumulative frequency of about 22% — of the National Health and Medical Research Council total funding between 2008 and 2014.4 A clear consequence is that CVD research suffers from brain drain, as emerging researchers seek sectors where funding is more available. This workforce crisis was highlighted by a recent Australian Cardiovascular Alliance survey, where 65% of CVD researchers say they would leave the sector if funding is not secured. Australian CVD research is of international standing, providing the highest returns of any disease group on research investment, an extraordinary $8 in health benefits for every $1 spent.4,5 The need for a committed workforce skilled in heart research is clear. Funds from the MRFF must be invested in research that reflects the health priorities and disease burden facing the nation, particularly where the market is failing. Such research is an investment not a cost. In 2017, the Heart Foundation will boost research investment by an additional $9.3 million. While substantial for the only major health charity supporting heart research, this is a drop in the ocean to what is needed. Proportionate investment will ensure that the great legacy of cardiovascular research in Australia is retained.

Garry LR Jennings · Jaye Chin-Dusting

To the Editor:In their article, Chen and Jepson1 discussed the advances in coronary artery stent technology. However, the review did not outline the indications for the newer and more expensive technologies mentioned, and did not indicate how stenting compares with the established practice of coronary artery bypass grafting (CABG) for patients with coronary artery disease. How does percutaneous coronary intervention (PCI) compare with CABG based on current evidence? The SYNTAX2 trial is a multinational trial investigating PCI versus CABG. At 5 years, the number of major adverse cardiovascular and cerebrovascular events in the CABG group was 26.9% compared with 37.3% in the PCI group. The 5-year myocardial infarction rate was 3.8% in the CABG group compared with 9.7% for PCI. Moreover, registry data showed that the cardiac death rate was 3.6% for CABG compared with 9.5% for PCI. Therefore, the group concluded that CABG should remain the standard of care for patients with multivessel coronary artery disease.2 A 2014 meta-analysis in JAMA3 comparing PCI with CABG indicated a reduction in mortality (relative risk [RR], 0.73; 95% confidence interval [CI], 0.62–0.86), myocardial infarction (RR, 0.58; 95% CI, 0.48–0.72) and revascularisation (RR, 0.29; 95% CI, 0.21–0.41), with CABG compared with PCI at a follow-up of 4.1 years. The subgroup analysis showed benefits in patients with and without diabetes. The BEST trial4 compares second generation everolimus-eluting stents with CABG. This trial enrolled 880 patients with more than 70% stenosis of two or more coronary arteries, and followed them up to 4.6 years. At 2 years, the primary endpoint of death, myocardial infarction or revascularisation occurred in 11% of patients in the PCI group and in only 7.9% of patients in the CABG group. During long term follow-up, it occurred in 15.3% of patients in the PCI group compared with 10.6% of patients in the CABG group.4 When reviewing the available evidence in the literature, several articles support CABG over PCI.5 The benefits of CABG persist, despite the development of second generation drug-eluting stents. CABG provides superior long term results in patients with multivessel coronary disease in regard to mortality, myocardial infarction and need for revascularisation. Therefore, CABG remains the gold standard of treatment for these patients.

Rohen Skiba · Chris Merry

In reply

Nigel Jepson · Daniel Chen

To the Editor: Since 1 October 2016, under changes in the Medicines Australia code of conduct,1 the names of all doctors receiving payments from pharmaceutical companies are being published online, together with the dollar amount received; the data will remain available for 3 years. Up until now, this information could only be published with the doctor’s consent. This change — part of the latest edition of the code of conduct — is the industry’s response to attempt to legislate for greater transparency. It represents a significant step forward in the transparency of the relationships between doctors and pharmaceutical companies. In 2015, pharmaceutical company-funded educational expenses for doctors included a $70 000 trip to Sweden for six oncologists and a $176 000 trip to Vancouver for nine dermatologists.2 With the new changes, it is likely that doctors will think twice before accepting large pharmaceutical company funding for educational events, given this information will be available to the public. Despite a considerable body of evidence showing that receipt of meals and sponsorship is associated with altered prescribing patterns,3,4 many doctors continue to incorrectly believe that they can effectively manage the influence of pharmaceutical company promotion on their decision making.4 The challenge for the profession is to foster doctor–pharmaceutical company relationships that benefit patients, while maintaining freedom from undue influence on prescribing habits. This requires system and individual change. Medicines Australia should be commended for its efforts to improve transparency; its measures are a lesson for other companies with financial interests relating to the practice and preferences of doctors, including medical devices companies. However, to fully realise the benefit of the code of conduct changes, all information on doctor payments must be accessible via a centralised repository that allows patients and third parties to search for an individual doctor. Regarding individual change, doctors must take heed of the evidence above and eschew gifts and education funding provided by pharmaceutical companies. Moreover, up to date and freely accessible evidence-based information is available via independent organisations such as NPS MedicineWise. Greater transparency in the relationships between doctors and pharmaceutical companies is a positive step to maintaining high levels of accountability and public trust in the medical profession.

Jessica Dean · Malcolm P Forbes · Richard Di Natale

Dr Christian Rowan is an addiction specialist who has taken his skills to Parliament

Cate Swannell

A Cairns immunologist who is investigating the benefits of hookworms for people with coeliac disease has been chosen as Queensland’s inaugural Emerging Science Leader. James Cook University researcher Dr Paul Giacomin is a researcher at the Australian Institute of Tropical Health and Medicine (AITHM) at JCU in Cairns. This award, to be made annually, identifies a current Queensland scientist who is creating breakthroughs in research, leading collaboration, advocating for science, and inspiring others to build a career in STEM (science, technology, engineering and mathematics). As an Emerging Science Leader, he will continue to actively advocate for Queensland science and highlight the achievements of scientists across the state, as well as supporting the Queensland Chief Scientist as an ambassador for science. His research investigates the key immune cells and cytokines involved in immunity to intestinal worms, as well as exploring the potential beneficial effects that worm infection may have in alleviating inflammation associated with autoimmune diseases. Professor Emma McBryde was awarded an Advance Queensland mid-career fellowship with funding of $300 000 to support her research on using a health system approach to combat antibiotic resistant infections. Professor McBryde’s research is conducted in partnership with the Townsville Hospital and Health Service. Dr Joseph Moxon received a mid-career fellowship with funding of $300 000 to support his clinical and economic evaluation of novel blood tests for stroke. Dr Moxon’s research is also conducted in partnership with the Townsville Hospital and Health Service. https://www.jcu.edu.au/news/releases/2017/march/queenslands-emerging-science-leader Monash University medical student Ms Masad Alfayadh has been awarded a Westpac Social Change Fellowship, acknowledging her work at Happy Brain Education, a not-for-profit organisation she co-founded that is changing the lives of young Australians through education. A final-year medical student at the School of Clinical Sciences at Monash Health (SCS), Masad is one of 10 social innovators to receive a Westpac Social Change Fellowship, valued at up to $50 000, through the Westpac Bicentennial Foundation. Masad co-founded Happy Brain Education (HBE), a not-for-profit mentoring and tutoring organisation that aims to empower young people through education and personal development. Masad said, apart from completing her medical training, her biggest focus in life was empowering young people experiencing social disadvantage, financial disadvantage and mental health issues. In 2003 when she was 10 years old, Masad and her family arrived in Australia as refugees from Iraq. Just 5 months later, Masad’s father was killed in a car accident, creating even more hardship for her family. Masad believes that education changed her life. Her Westpac Fellowship will enable her to complete a Certificate of Social Innovation and Entrepreneurship at Stanford University, a Graduate Certificate in Social Impact at Swinburne University and two courses at the University of Oxford, one on global social movements and another in management. She also hopes to use the scholarship to volunteer with Medecins Sans Frontieres and to further her charity work to help more people around Australia. http://www.monash.edu/medicine/news/latest/articles/monash-medical-student-changing-lives-and-awarded-westpac-fellowship2 Monash University Biomedicine Discovery Institute PhD student Dr Amy Winship’s research has been recognised with a Highly Commended award at the Victorian Premier’s Award for Health and Medical Research. Dr Winship discovered a protein that may be a cause of pre-eclampsia and uterine cancer. Her studies, done in an animal model and in human tissue, revealed that blocking the effects of this protein may lead to prevention of pre-eclampsia and, more importantly, block the growth and spread of the uterine cancer. In the placenta the factor, called IL-11, restricts the normal growth of the placenta, causing the development of pre-eclampsia in animal models. High levels of IL-11 were also found in the blood of women before they developed pre-eclampsia, which could lead to the development of a new test to diagnose the disorder. When in the uterus, IL-11 promotes growth of cancer in the uterus in animal models. Dr Winship’s studies revealed that, when IL-11 is blocked with an antibody, the uterine cancer reduced in size and did not metastasize compared with controls where the cancer spread. According to Dr Winship, the antibody, developed by CSL, is able to be used in humans, opening the way for it to be used as a treatment to prevent pre-eclampsia and to treat uterine cancer. Currently the treatment for uterine cancer is hysterectomy and chemotherapy or radiotherapy, both of which can affect a women’s fertility. Blocking IL-11, in animal and human laboratory studies, did not have any long-term effects such as reducing fertility. Dr Katherin Gibney was also highly commended for her research done at the Monash Department of Epidemiology and Preventive Medicine under the supervision of Professor Karin Leder. Dr Gibney, now at the Doherty Institute, was awarded for her work on socioeconomic inequities in infectious diseases in Australia. http://www.monash.edu/medicine/news/latest/articles/monash-researcher-recognised-for-potential-treatment-for-preeclampsia-and-uterine-cancer Heidi Fettke, a translational PhD student at the School of Clinical Sciences at Monash Health (SCS), has been awarded the Nairn Prize in Immunology. The Nairn Prize is given to the top Honours student each year enrolled in immunology at Monash University. Heidi was awarded the prize for her Bachelor of Science (Honours) project, where she investigated the potential role of the c-Myc oncogene in driving expression of an immuno-inhibitory molecule, PD-L1, in glioblastoma tumours. Heidi completed her project under the supervision of Professor Terrance Johns, Centre for Cancer Research at the Hudson Institute of Medical Research. Heidi is currently researching biomarkers in metastatic castration-resistant prostate cancer under the supervision of Associate Professor Arun Azad, Department of Medicine. http://www.monash.edu/medicine/news/latest/articles/scs-student-wins-top-prize-in-immunology Professor Kieran Harvey joins Monash University’s Biomedicine Discovery Institute, as a joint appointment with the Peter MacCallum Cancer Centre. As the fourth joint appointment between the two research institutes, Professor Harvey’s appointment at the Monash BDI, while continuing with his substantive appointment at the Peter MacCallum Cancer Centre, will increase the collaboration between the two research entities and is a great example of a partnership that promotes the acceleration of discoveries to the clinic. Further strengthening the Institute’s Development and Stem Cell, and Cancer, Discovery Programs, Professor Harvey brings a creative skill set that draws on live organ culture, advanced microscopy techniques and CRISPR genome editing to dissect the roles of genes and their products in the major signalling network “Hippo”, which controls organ development. Using the fruit fly Drosophila as a model organism, Professor Harvey and his team have discovered a large number of important proteins in the evolutionarily conserved Hippo pathway, including the founding pathway members and first transmembrane receptor. Professor Harvey was awarded his PhD from Adelaide University in 2000. He held postdoctoral positions at Massachusetts General Hospital/Harvard Medical Centre in Boston and the University of California at Berkeley, before establishing his own group at the Peter MacCallum Cancer Centre in 2006. He was awarded the 2014 Gottschalk Medal by the Australian Academy of Science for outstanding research in the medical sciences. http://www.monash.edu/medicine/news/latest/articles/new-joint-appointment-strengthens-collaboration-between-monash-biomedicine-discovery-institute-and-petermac Professor Elizabeth Molloy has been appointed Professor in Work Integrated Learning in the Department of Medical Education, Melbourne Medical School. Professor Molloy was previously Director of the Health Professions Education and Educational Research Centre at Monash University (2011-2015). She has published more than 90 peer-reviewed journal articles, book chapters and books, with a focus on workplace learning, feedback, assessment, professional transitions, and clinical teacher professional development. Her PhD at the University of Melbourne (2006) examined the role of the clinical educator in providing performance feedback to students. As well as teacher education (postgraduate award courses in health professions education), she is involved in designing and evaluating innovations to improve the preparation of medical students and postgraduate medical trainees to learn in the workplace. Professor Molloy was Chair of the Australian Physiotherapy Educators’ Group (2012-2014), is a member of the Academy of Surgical Educators, and is a Fellow of the Australian and New Zealand Association for Health Professions Education. She is currently working on two Category 1 funded research projects. One examines how post-practicum interventions accelerate learners’ preparation for practice and the other looks at feedback practices across higher education in Australia. Work integrated learning is a growing field of study, and Prof Molloy’s work will seek to better link what students learn in theory to practice in the clinical workplace. Activities and assessments that encourage individuals to be learners rather than students need to be embedded day one, year one and reinforced over the years. For this reason, she will be working in partnership with clinical schools and departments, piloting and evaluating strategies to achieve this within the MD. http://medicine.unimelb.edu.au/news-and-events/welcome-professor-elizabeth-molloy-to-the-department-of-medical-education

Cate Swannell