Medical practices

A 75-year-old man presented with three days of lethargy and diarrhoea

Noor Lammoza · Maria Hormiz · Cherie Chiang · Chris Stead · Mustafa Ayhan · Samuel C Hume

A 16-year-old female patient with cystic fibrosis developed recurrent pleural effusions, facial plethora and prominent chest wall veins

John J Harvey · John I Vrazas · Elhamy Bekhit · Chris Barnes · Philip J Robinson

Management of critical bleeding requires a multidisciplinary approach to haemorrhage control, correction and prevention of coagulopathy, and normalisation of physiological derangements

for the Clinical and Consumer Reference Group for the Update of Patient Blood Management Guidelines (Module 1: Critical Bleeding/Massive Transfusion)

Unrelated findings on imaging studies are increasingly common and how to interpret and manage them is challenging

Ian A Scott · John Slavotinek · Paul P Glasziou

A 56-year-old woman of European ancestry from a suburban area of Far North Queensland was referred to the local cardiothoracic unit for a right lower lobe lung lesion

Sigrid G Theodore · Hannah J Sawkins · Manish Mathew · Sumit Yadav · Robert Norton

Accurate diagnosis requires careful interpretation of laboratory results, with repeat serology over time and using a range of different assays

Kate Proudmore · Vicki L Krause · Bart J Currie · Rob Baird

A commitment to culturally appropriate codesign processes will shape the development of an equitable lung cancer screening pathway

Alison Brown · Gail Garvey · Nicole M Rankin · Claire Nightingale · Lisa J Whop

Choosing therapies well, with the patient’s preference, requires an understanding of the temporal risk profile of coronary artery disease

Derek P Chew · Sarah Zaman

The availability of evidence-based therapies should be seen as a call to action to urgently streamline and unify the diagnosis of HFpEF at the clinical interface

Sandhir B Prasad · David J Holland · John J Atherton

A 19-year-old male student with a history of asthma and nut anaphylaxis was taken by ambulance to hospital when he was found unresponsive with vomitus and faecal soiling after one day of lethargy and sore throat

Gary Louie · Romeo Torres · Anthea L Katelaris · Courtney McGregor · Victor Lai · Robert Stevens · Richard Sullivan · Pamela Konecny

Improving diagnostic capabilities in rural areas will require a commensurate increase in clinical decision-making and therapeutic capacity

Taylor Strube · Derek P Chew

Local assessment could improve access to cardiac services in rural centres and reduce the costs associated with sending patients to Perth

Mikhail Alexander · Nick S R Lan · Michael J Dallo · Tom G Briffa · Frank M Sanfilippo · Andrew Hooper · Helen Bartholomew · Loletta Hii · Graham S Hillis · Brendan M McQuillan · Girish Dwivedi · James M Rankin · Abdul Rahman Ihdayhid

Blood donor screening laboratories use different testing algorithms to diagnostic laboratories and may yield results which do not conform to the usual patterns with which clinicians are familiar

Christopher D Swan · Clive R Seed · Claire E Styles · Iain B Gosbell

Melanie Bahlo

Routine testing removes barriers to testing, identifies additional women with pathogenic variants, leading to revised treatment for many

Dilanka L De Silva · Lesley Stafford · Anita R Skandarajah · Michelle Sinclair · Lisa Devereux · Kirsten Hogg · Maira Kentwell · Allan Park · Luxi Lal · Magnus Zethoven · Madawa W Jayawardana · Fiona Chan · Phyllis N Butow · Paul A James · G Bruce Mann · Ian G Campbell · Geoffrey J Lindeman

Clinically meaningful outcomes can be achieved with matched germline/tumour whole genome sequencing

The Q‐IMPROvE study group

The management of cutaneous melanoma has been revolutionised in the past decade, with ongoing efforts to improve patient outcomes centred on rich translational research endeavours and robust clinical trials

Prachi Bhave · Jessica Wong · Aideen McInerney‐Leo · Anne E Cust · Craig Lawn · Monika Janda · Victoria J Mar

A 78-year-old man with hypertension, dyslipidaemia, hypothyroidism and gout presented with two weeks of migratory polyarthritis and fever

Hannah Poole · Amy Crowe · John Daffy

SUDI investigations should be led by coroners, supported by experienced paediatric pathologists Jeffery and colleagues examined how sudden unexpected deaths in infancy (SUDI) are investigated in Australia in a questionnaire‐based study,1 reported in this issue of the MJA. They unsurprisingly exposed gaps in the process and unsuitable approaches to investigating these deaths. As Jeffery and colleagues note, the definition of SUDI encompasses all cases in which an infant dies (or suffers a collapse that leads to death) before the age of twelve months, the death could not have been anticipated 24 hours earlier, and no medical cause is apparent. The SUDI definition includes all such deaths, whether they are subsequently explained or not, and thus encompasses sudden infant death syndrome (SIDS), a diagnosis that requires a complete investigation, including history, death scene investigation, and full autopsy. In the absence of generally recognised causes, the investigation of SUDI is a special situation: each case is a subject of research or a problem to be solved. Most cases in Australia fall within the purview of the police and the state coroner. While their questionnaire methodology had inherent limitations, Jeffery and colleagues found that police‐led investigation fell short of evidence‐based standards. Obvious problems are related to inadequate resources and the lack of a national approach to investigating unexpected deaths in infancy, including a national autopsy protocol. In some states, forensic institutions perform autopsies under the jurisdiction of the coroner. Only one employs a paediatric pathologist for this purpose, despite the fact that SUDI autopsy is a specialist procedure. Problems arise when pathologists without relevant specialist expertise overlook key aspects or misinterpret important findings; this can result in unsafe legal outcomes. In 1989, the late SIDS expert forensic pathologist Professor John Hilton discussed the fact that the investigation of SIDS is encumbered by unusual limitations.2 These limitations are pertinent to the study by Jeffery and colleagues, including ethical questions regarding consent for obtaining and retaining tissue, and difficulty in obtaining suitable control material for meaningful research. The specific causes of many cases of SUDI and SIDS remain unknown, despite the resources of 21st century science. Limitations to their investigation may play a role, but there are a number of plausible research hypotheses, especially that centred on the homeostatic control of breathing, arousal, and cardiac function.3 However, it is worrying that few neuropathological or neurotransmitter findings have been linked with SIDS risk factors.4 In contrast, the list of risk factors linked with infection‐based hypotheses (eg, the bacterial toxin hypothesis)5,6 is extensive,7,8 especially strong associations with prone sleeping and the type of sleeping surface.9,10,11 Achieving clarification may require, as demanded by Jeffery and colleagues, the implementation of core components of international standards, such as those recommended by the Kennedy Report,12 including a standardised autopsy protocol. Doing so would maximise the probability that the cause of death is elucidated, and ensure that risk factors are identified, parents and families receive immediate and ongoing support, and the consequences of incorrect diagnosis are avoided. SUDI investigations should be led by coroners, supported by experienced paediatric pathologists playing pivotal roles. A national database of SUDI data could also be helpful for research and monitoring standards, but this will require dedicated financial support.

Paul N Goldwater

Therapeutic advancement is well underway, and the medical community needs to keep pace

Amy Brodtmann · David Darby · Carly Oboudiyat · Colin J Mahoney · Campbell Le Heron · Peter K Panegyres · Bruce Brew