Volume 207 Issue 7

Unwarranted variation in health care requires action from all players in health — including clinical colleges

Helen Francombe · Heather A Buchan · Anne Duggan

A recent trial provides high quality new evidence

Paul Bird · Terrence Diamond · William A Clark

A 79-year-old woman presented with 10 kg unintentional weight loss, anorexia, fatigue and cough over 3 months

Anver M Sethwala

A 53-year-old woman presented with 2 weeks of lethargy, vomiting, dizziness and confusion following a respiratory tract infection

Melissa H Lee · Genevieve L Calder · Richard J MacIsaac · Nirupa Sachithanandan

29 June 1930 - 18 January 2017

Christine M Shearman

16 September 1927 - 4 March 2017

Susan J Wareham

Handbook of cannabis

David Allsop

Therapeutic development should not forget the symptoms

Peter J Nestor*

Broader acceptance of organs from circulatory death donors would increase donor rates significantly

Richard DM Allen · Henry CC Pleass

Clinical trials in maternal and perinatal health care can be valuable if their findings are adopted in clinical practice

Clarabelle T Pham · Jonathan D Karnon · Philippa F Middleton · Frank H Bloomfield · Katie M Groom · Caroline A Crowther · Ben W Mol

The untapped potential in Australia for DCD, particularly of kidneys and lungs, is significant

Sandeep S Rakhra · Helen I Opdam · Laura Gladkis · Byron Arcia · Michael A Fink · John Kanellis · Peter S Macdonald · Gregory I Snell · David V Pilcher

As new vaccine programs are introduced for older people, vaccine pharmacovigilance must be improved

Hazel J Clothier · Nigel W Crawford · Melissa Russell · Jim P Buttery

Detailed medical history, carer information, targeted neuropsychological testing and brain neuroimaging help to differentiate bvFTD from other dementia syndromes

Olivier Piguet · Fiona Kumfor · John Hodges

Irritable bowel syndrome (IBS) and other functional gastrointestinal disorders are so prevalent they cannot reasonably have their diagnoses and management based within specialty care

Ecushla C Linedale · Jane M Andrews

To the Editor:Cadilhac and colleagues1 explore an important issue in the measurement and reporting of stroke outcomes. We agree that appropriate risk-adjustment methods are essential to compare hospital outcomes. We also agree that stroke severity is an important predictor of mortality for individual patients. However, we do not agree that determining stroke severity is essential for robust risk-adjustment approaches. The Bureau of Health Information has recently published its second report on 30-day mortality.2 Our approach includes adjustment for comorbidity, and we developed separate models for ischaemic and haemorrhagic stroke, given the significant differences in outcomes and risk factors. The approach of Cadilhac and colleagues does neither, which means that we do not know the impact of including comorbidity adjustment and severity in the same model. Further, our method is applicable to small hospitals with as few as 50 patients in a 3-year period. In settings such as Australia, where many patients reside outside major cities, it is important to assess outcomes in both small and large hospitals. The results of Cadhilac et al show that adjusting for stroke severity affected hospital rankings, and across the two models, hospital rates changed on average by 0.01 (range, 0.001–0.026). The impact on outlier status is not described. In our view, it is the outlier status that is the most salient element of public reporting, and indirect standardisation should not be used to rank hospitals.3 Measurement approaches in the United States and Canada do not adjust for severity, and it is not currently possible to do so using administrative records in Australia. While Cadhilac et al have shown that including severity information can affect rankings, such rankings are not appropriate to assess hospital performance when they are based on indirect standardisation and do not take account of hospital size.

Kim Sutherland · Jean-Frederic Levesque · Julia Chessman

In reply

Monique Kilkenny · Leonid Churilov · Dominique A Cadilhac

To the Editor:We thank Tong and colleagues1 for their report on a patient with schizophrenia and clozapine-induced maculopathy, and for highlighting this under-recognised condition. Both typical2 and atypical3 antipsychotic drugs have been reported to cause widespread retinopathy; more recently, there have been reports of rare cases of retinal damage localised to the macula (maculopathy) due to both typical4 and atypical1,5 antipsychotics. The classical hypothesis for widespread pigmentary retinopathy is that drugs are absorbed by melanin in the retinal pigment epithelium (RPE) and act as photosensitisers to damage the RPE. This results in loss of RPE support functions of overlying photoreceptors, which secondarily degenerate. An alternative hypothesis,2 supported by histological and animal studies, is that the problem begins in photoreceptors, with drug-induced blockade of retinal dopamine receptors followed by photoreceptor and subsequent RPE cell loss. Neuroleptic retinal drug toxicity typically involves pigment disruption in the RPE, but the dopamine hypothesis allows for broader combinations of RPE and/or photoreceptor damage. The reasons for the development of maculopathy in some patients, rather than a widespread retinopathy, are not known. This phenomenon is seen in other ocular drug toxicities, particularly hydroxychloroquine. Most drug-induced retinal toxicities are bilateral and symmetrical; asymmetrical cases have rarely been reported. The patient reported by Tong and colleagues is atypical with apparently unilateral macular changes.1 Significant differential diagnoses for unilateral macular pigment and photoreceptor changes include age-related and secondary to retinal conditions, such as central serous chorioretinopathy, inflammatory retinopathies and trauma. Maculopathy limited to the outer neuroretina may occur with the use of other drugs (eg, poppers maculopathy).6 Also, schizophrenia is known to cause illness-related retinal changes in the neuroretina but not in the RPE.7 We agree that patients taking psychotropic medications benefit from a multidisciplinary approach when ocular symptoms and signs develop.

Heather G Mack · RC Andrew Symons

In reply

Jessica Y Tong · Amy Pai · Stephanie H Young

Times Higher Education has released its annual ranking of the world’s universities and the University of Melbourne is the best of the Aussies

Cate Swannell

The 2017 Australian Museum Eureka Prizes have been awarded and health and medicine researchers featured heavily. Professor Geoffrey Webb, from Monash University, won the UTS Eureka Prize for Excellence in Data Science for his work, which has included supporting research into male suicide and a range of diseases, and has had significant social and economic impact. The Scabies Research Team, from the Murdoch Childrens Research Institute, the Kirby Institute, St Vincent’s Hospital Sydney and the Menzies School of Health Research, won the Australian Infectious Diseases Research Centre Eureka Prize for Infectious Diseases Research for two landmark trials showing that mass drug administration with the oral drug ivermectin is highly effective in controlling scabies and related bacterial skin sores. The Johnson and Johnson Eureka Prize for Innovation in Medical Research went to the Colvera Team from the CSIRO, Clinical Genomics P/L and Flinders University, for developing a clinically validated blood test that sensitively and accurately detects cancer DNA in the blood plasma of colorectal cancer patients. ANSTO Eureka Prize for Innovative Use of Technology went to the FREO2 Siphon concentrator at the University of Melbourne, which stores and delivers medical-grade oxygen to critically ill newborn babies without needing a secure source of electricity, with the potential to substantially reduce infant mortality rates arising from hypoxic illnesses in low-resource settings, such as Papua New Guinea, East Timor and sub-Saharan Africa. The UNSW Eureka Prize for Scientific Research was won by Bacteria Busters at Swinburne University of Technology, where Professor Elena Ivanova and Professor Saulius Juodkazis showed that mimicking the nanomorphology of insect wings is an effective method of preventing bacterial colonisation. Their approach of providing a physical, rather than chemical, means of killing bacteria could have a huge impact on public health worldwide. Professor Andrew Whitehouse, from the Telethon Kids Institute, won the 3M Eureka Prize for Emerging Leader in Science, for his work helping children with autism reach their full potential. Professor Justin Gooding (pictured) from the University of New South Wales, won the UTS Eureka Prize for Outstanding Mentor of Young Researchers, for training and developing an all-new breed of research leader in bionanotechnology and nanomedicine. https://australianmuseum.net.au/2017-eureka-prizes-winners Monash University’s Faculty of Medicine, Nursing and Health has announced the winners of the 2017 Dean’s Awards for Excellence. Dean’s Award for Excellence in Research Impact (Economic and Social Impact): Professor Michael Abramson, Professor Judi Walker, Professor Malcolm Sim (pictured), Dr Matthew Carroll and the Hazelwood Health Study Project Management Group, School of Rural Health and School of Public Health and Preventive Medicine; Dean’s Award for Excellence in Research (Early Career): Dr Eric Chow, Central Clinical School; Dean’s Award for Doctoral Thesis Excellence: Dr Jae Young Lee, Central Clinical School; Dean’s Award for Excellence in Education (Honours Supervision): Dr Ted Brown, School of Primary and Allied Health Care; Dean’s Award for Excellence in Education (Quality of Teaching): Dr Simone Gibson, School of Clinical Sciences; Dean’s Award for Excellence in Education (Innovation in Teaching): Dr Dana Wong, School of Psychological Sciences; Dr Julia Choate and the Biomedical Professional Development team of Ms Sandra Cran, Associate Professor Janet Macaulay, Dr Maria Demaria, Ms Judi Green from the School of Biomedical Sciences; Dean’s Award for Excellence in Diversity and Inclusion: Dr Rebecca Lane and the NICHE team: Ms Jo-Anne Corbett, Ms Prue Munro, Dr Adela Abu-Arab, School of Primary and Allied Health Care; Dean’s Award for Excellence in Safety: Ms Rebecca Flower, School of Biomedical Sciences; Dean’s Award for Excellence in Administration: Ms Ruth Fantozzi, School of Clinical Sciences, Ms Sharon Gurry, School of Public Health and Preventive Medicine; Physiology Practical Teaching Laboratory Officer team: Ms Barbara Smith, Ms Kushani Weerakoon, Ms Svetlana Stanojkovic, Ms Alda Retre, Ms Sofie Saleh; School of Biomedical Sciences. http://www.monash.edu/medicine/news/latest/articles/2017-deans-awards-for-excellence Monash University researcher Dr Daniella Brasacchio has received the 2017 Pink Hope Outreach Ambassadors Award in recognition of her scientific and public advocacy work, raising awareness of hereditary breast and ovarian cancer. A senior research fellow in the Blood Cancer Therapeutics Laboratory, School of Clinical Sciences at Monash Health, Dr Brasacchio has been recognised by the preventative health organisation Pink Hope for helping to raise awareness of hereditary cancer, promoting the work of Pink Hope and supporting high risk families. Pink Hope works to ensure every individual can assess, manage and reduce their risk of breast and ovarian cancer, while providing personalised support for at risk women. While Dr Brasacchio’s research at Monash University is not connected to hereditary breast and ovarian cancer—she investigates blood cancers including myeloma and lymphoma—she believes it’s extremely important for scientists to use their skills and knowledge to positively communicate research to the community. https://www.monash.edu/medicine/news/latest/articles/monash-researcher-receives-2017-pink-hope-outreach-ambassadors-award