Topics

Medical assistance in dying may disrupt therapeutic relationships and will challenge beliefs

Medical assistance in dying, whether voluntary euthanasia or physician-assisted suicide, has been a recurring topic for societal debate. Voluntary euthanasia is the deliberate and intentional act to end a competent person’s life, at their request, to relieve their suffering.1 Physician-assisted suicide relates to the medical provision of the means or knowledge for someone to commit suicide via the self-administration of a prescribed medication.1 Amid growing societal support2 and stability of worldwide medical opinion, there has been a 66% increase in the legalisation of physician-assisted suicide since 2015,3 which indirectly legitimises such practices through the broad influence it has on societal support. Canada and the American states of California and Colorado legalised physician-assisted suicide in 2016.3 In Australia, the Victorian Parliament passed a Bill in 2017 to legalise physician-assisted suicide, while the debate currently continues in other Australian states and New Zealand. By contrast, in May 2018 Guernsey failed to become the first place in Britain to permit physician-assisted suicide.4

1 Eastern Health, Melbourne, VIC
2 Monash University, Melbourne, VIC

Correspondence: leeroy.william@monash.edu

Competing interests:

No relevant disclosures.

1. Queensland University of Technology. End of life law in Australia. Euthanasia and assisted dying. https://end-of-life.qut.edu.au/euthanasia#547411 (accessed Aug 2018).
2. Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA 2016; 316: 79-90.
3. Kennedy Institute of Ethics, Georgetown University. Euthanasia regulations around the world. https://ethicslab.georgetown.edu/euthanasia-map/ (accessed Aug 2018).
4. Sherwood H. Guernsey parliament votes against assisted dying. The Guardian 2018; 18 May. https://www.theguardian.com/society/2018/may/18/guernsey-parliament-votes-against-assisted-dying (accessed Aug 2018).
5. Hendry M, Pasterfield D, Lewis R, et al. Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying. Palliat Med 2012; 27: 13-26.
6. Kelly BJ, Varghese FT, Pelusi D. Countertransference and ethics: a perspective on clinical dilemmas in end-of-life decisions. Palliat Support Care 2003; 1: 367-375.
7. Saini V, Garcia-Armesto S, Klemperer D, et al. Drivers of poor medical care. Lancet 2017; 390: 178-190.
8. Estacio CF, Butow PN, Lovell MR, et al. Exploring symptom meaning: perspectives of palliative care physicians. Support Care Cancer 2018; 26: 2769-2784.
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10. Working Party of the Royal College of Physicians. Doctors in society: medical professionalism in a changing world. Clin Med (Lond) 2005; 5 (6 Suppl 1): S5-S40.
11. Bergman YS, Bodner E, Haber Y. The connection between subjective nearness-to-death and depressive symptoms: the mediating role of meaning in life. Psychiatry Res 2018; 261: 269-273.
12. McKenzie EL, Brown PM, Mak AS, Chamberlain P. “Old and ill”: death anxiety and coping strategies influencing health professionals’ well-being and dementia care. Aging Ment Health 2017; 21: 634-641.
13. Belmi P, Pfeffer J. Power and death: mortality salience increases power seeking while feeling powerful reduces death anxiety. J Appl Psychol 2016; 101: 702-720.
14. Virdun C, Luckett T, Lorenz K, et al. Dying in the hospital setting: a meta-synthesis identifying the elements of end-of-life care that patients and their families describe as being important. Palliat Med 2017; 31: 587-601.
15. Smith C, Bosanquet N, Riley J, Koffman J. Loss, transition and trust: perspectives of terminally ill patients and their oncologists when transferring care from the hospital into the community at the end of life. BMJ Support Palliat Care 2016; doi: 10.1136/bmjspcare-2015-001075.
16. Wong PTP, Reker GT, Gesser G. Death attitude profile-revised: a multidimensional measure of attitudes toward death. In: Neimeyer RA. Death anxiety handbook: research, instrumentation, and application. Washington DC: Taylor & Francis, 1994.
17. Thiemann P, Quince T, Benson J, et al. Medical students’ death anxiety: severity and association with psychological health and attitudes toward palliative care. J Pain Symptom Manage 2015; 50: 335-342.

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Research

Surveillance improves survival of patients with hepatocellular carcinoma: a prospective population-based study

Thai P Hong, Paul J Gow, Michael Fink, Anouk Dev, Stuart K Roberts, Amanda Nicoll, John S Lubel, Ian Kronborg, Niranjan Arachchi, Marno Ryan, William W Kemp, Virginia Knight, Vijaya Sundararajan, Paul Desmond, Alexander JV Thompson and Sally J Bell

Med J Aust 2018; 209 (8): . || doi: 10.5694/mja18.00373
Published online: 24 September 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Neoplasms

Digestive system diseases

Environment and public health

Statistics, epidemiology and research design

Abstract

Objectives: To determine the factors associated with survival of patients with hepatocellular carcinoma (HCC) and the effect of HCC surveillance on survival.

Design, setting and participants: Prospective population-based cohort study of patients newly diagnosed with HCC in seven tertiary hospitals in Melbourne, 1 July 2012 – 30 June 2013.

Main outcome measures: Overall survival (maximum follow-up, 24 months); factors associated with HCC surveillance participation and survival.

Results: 272 people were diagnosed with incident HCC during the study period; the most common risk factors were hepatitis C virus infection (41%), alcohol-related liver disease (39%), and hepatitis B virus infection (22%). Only 40% of patients participated in HCC surveillance at the time of diagnosis; participation was significantly higher among patients with smaller median tumour size (participants, 2.8 cm; non-participants, 6.0 cm; P < 0.001) and earlier Barcelona Clinic Liver Cancer (BCLC) stage disease (A/B, 59%; C/D, 25%; P < 0.001). Participation was higher among patients with compensated cirrhosis or hepatitis C infections; it was lower among those with alcohol-related liver disease or decompensated liver disease. Median overall survival time was 20.8 months; mean survival time was 18.1 months (95% CI, 16.6–19.6 months). Participation in HCC surveillance was associated with significantly lower mortality (adjusted hazard ratio [aHR], 0.60; 95% CI, 0.38–0.93; P = 0.021), as were curative therapies (aHR, 0.33; 95% CI, 0.19–0.58). Conversely, higher Child–Pugh class, alpha-fetoprotein levels over 400 kU/L, and later BCLC disease stages were each associated with higher mortality.

Conclusions: Survival for patients with HCC is poor, but may be improved by surveillance, associated with the identification of earlier stage tumours, enabling curative therapies to be initiated.

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1 St Vincent's Hospital Melbourne, Melbourne, VIC
2 Austin Hospital, Melbourne, VIC
3 University of Melbourne, Melbourne, VIC
4 Austin Health, Melbourne, VIC
5 Monash Health, Melbourne, VIC
6 Eastern Health, Melbourne, VIC
7 Western Health, Melbourne, VIC
8 Alfred Hospital, Melbourne, VIC

Correspondence: thai.hong@svha.org.au

Competing interests:

No relevant disclosures.

1. Forman D, Bray F, Brewster DH, et al, editors. Cancer incidence in five continents. Volume X (IARC Scientific Publication No. 164). Lyon: International Agency for Research on Cancer, 2014. http://publications.iarc.fr/Book-And-Report-Series/Iarc-Scientific-Publications/Cancer-Incidence-In-Five-Continents-Volume-X-2014 (viewed Aug 2018).
2. MacLachlan JH, Cowie BC. Liver cancer is the fastest increasing cause of cancer death in Australians. Med J Aust 2012; 197: 492-493. <MJA full text>
3. Leung C. Characteristics of hepatocellular carcinoma in cirrhotic and non-cirrhotic non-alcoholic fatty liver disease. World J Gastroenterol 2015; 21: 1189-1196.
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7. Weinmann A, Koch S, Niederle IM, et al. Trends in epidemiology, treatment, and survival of hepatocellular carcinoma patients between 1998 and 2009: an analysis of 1066 cases of a German HCC Registry. J Clin Gastroenterol 2014; 48: 279-289.
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12. Davila JA, Henderson L, Kramer JR, et al. Utilization of surveillance for hepatocellular carcinoma among hepatitis C virus-infected veterans in the United States. Ann Intern Med 2011; 154: 85-93.
13. Park SH, Heo NY, Park JH, et al. Hepatocellular carcinoma screening in a hepatitis B virus-infected Korean population. Dig Dis Sci 2012; 57: 3258-3564.
14. Hong TP, Gow P, Fink M, et al. Novel population-based study finding higher than reported hepatocellular carcinoma incidence suggests an updated approach is needed. Hepatology 2016; 63: 1205-1212.
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16. Australian Institute of Health and Welfare. Cancer in Australia: an overview 2014 (AIHW Cat. No. CAN 88; Cancer Series No. 90). Canberra: AIHW, 2014.
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18. Welzel TM, Graubard BI, Quraishi S, et al. Population-attributable fractions of risk factors for hepatocellular carcinoma in the United States. Am J Gastroenterol 2013; 108: 1314-1321.
19. Lin ZH, Xin YN, Dong QJ, et al. Performance of the aspartate aminotransferase-to-platelet ratio index for the staging of hepatitis C-related fibrosis: an updated meta-analysis. Hepatology 2011; 53: 726-736.
20. Bloom S, Kemp W, Nicoll A, et al. Liver stiffness measurement in the primary care setting detects high rates of advanced fibrosis and predicts liver-related events in hepatitis C. J Hepatol 2018; 69: 575-583.
21. Robotin MC, Kansil M, Howard K, et al. Antiviral therapy for hepatitis B-related liver cancer prevention is more cost-effective than cancer screening. J Hepatol 2009; 50: 990-998.
22. Strasser SI. Managing hepatitis B to prevent liver cancer: recent advances. Expert Rev Gastroenterol Hepatol 2014; 8: 409-415.
23. Chen JG, Parkin DM, Chen QG, et al. Screening for liver cancer: results of a randomised controlled trial in Qidong, China. J Med Screen 2003; 10: 204-209.
24. Poustchi H, Farrell GC, Strasser SI, et al. Feasibility of conducting a randomized control trial for liver cancer screening: Is a randomized controlled trial for liver cancer screening feasible or still needed? Hepatology 2011; 54: 1998-2004.
25. Cucchetti A, Trevisani F, Pecorelli A, et al. Estimation of lead-time bias and its impact on the outcome of surveillance for the early diagnosis of hepatocellular carcinoma. J Hepatol 2014; 61: 333-341.

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Meta-analysis

Helicobacter pylori infection and the risk of upper gastrointestinal bleeding in low dose aspirin users: systematic review and meta-analysis

Justin CH Ng and Neville David Yeomans

Med J Aust 2018; 209 (7): . || doi: 10.5694/mja17.01274
Published online: 24 September 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Digestive system diseases

Pharmaceutical preparations

Abstract

Objective: To determine whether the risk of upper gastrointestinal bleeding in patients taking low dose aspirin (≤ 325 mg/day) is increased in people with Helicobacter pylori infections.

Study design: A systematic search for all publications since 1989 (when H. pylori was named) using search term equivalents for “upper gastrointestinal haemorrhage” and “aspirin”. Articles were assessed individually for inclusion of data on H. pylori infection, as not all relevant papers were indexed with this term. Data that could be pooled were then subjected to meta-analysis, using a random effects model.

Data sources: MEDLINE, Embase, Scopus, the Cochrane Library.

Data synthesis: Of 7599 retrieved publications, reports for seven case–control studies contained data suitable for meta-analysis; four were deemed high quality on the Newcastle–Ottawa scale. Upper gastrointestinal haemorrhage was more frequent in aspirin users infected with H. pylori than in those who were not (odds ratio [OR], 2.32; 95% CI, 1.25–4.33; P = 0.008). The heterogeneity of the studies was significant (Q = 19.3, P = 0.004; I² = 68.9%, 95% CI, 31.5–85.9%), but the pooled odds ratio was similar after removing the two studies that contributed most to heterogeneity (OR, 2.34; 95% CI, 1.56–3.53; P < 0.001). The number needed to treat to prevent one bleeding event annually was estimated to be between 100 and more than 1000.

Conclusions: The odds of upper gastrointestinal bleeding in patients taking low dose aspirin is about twice as great in those infected with H. pylori. Testing for and treating the infection should be considered in such patients, especially if their underlying risk of peptic ulcer bleeding is already high.

1 University of Melbourne, Melbourne, VIC
2 Peninsula Health, Melbourne, VIC
3 Austin Health, Melbourne, VIC

Correspondence: JNg@phcn.vic.gov.au

Acknowledgements:

We thank Helen Baxter and Shanti Nadaraja (Austin Health Sciences Library, Austin Health) for expert assistance with the structured literature searches.

Competing interests:

No relevant disclosures.

1. Patrono C. Aspirin: new cardiovascular uses for an old drug. Am J Med 2001; 110 (Suppl 1A): 62S-65S.
2. Taha AS, Angerson WJ, Knill-Jones RP, et al. Upper gastrointestinal haemorrhage associated with low-dose aspirin and anti-thrombotic drugs: a 6-year analysis and comparison with non-steroidal anti-inflammatory drugs. Aliment Pharmacol Ther 2005; 22: 285-289.
3. Taha AS, Angerson WJ, Prasad R, et al. Upper gastrointestinal bleeding and the changing use of COX-2 non-steroidal anti-inflammatory drugs and low-dose aspirin. Aliment Pharmacol Ther 2007; 26: 1171-1178.
4. Lanza FL, Chan FK, Quigley EM, et al. Guidelines for prevention of NSAID-related ulcer complications. Am J Gastroenterol 2009; 104: 728-738.
5. Lanas A. Gastrointestinal bleeding associated with low-dose aspirin use: relevance and management in clinical practice. Expert Opin Drug Saf 2011; 10: 45-54.
6. Fletcher EH, Johnston DE, Fisher CR, et al. Helicobacter pylori and the risk of upper gastrointestinal bleeding risk in patients taking aspirin. Aliment Pharmacol Ther 2010; 32: 831-839.
7. Bhatt DL, Scheiman J, Abraham NS, et al. ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol 2008; 52: 1502-1517.
8. Chey WD, Leontiadis GI, Howden CW, et al. ACG clinical guideline: treatment of Helicobacter pylori infection. Am J Gastroenterol 2017; 112: 212-238.
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Narrative review

When to initiate dialysis for end-stage kidney disease: evidence and challenges

Titi Chen, Vincent WS Lee and David C Harris

Med J Aust 2018; 209 (6): . || doi: 10.5694/mja18.00297
Published online: 17 September 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Urologic diseases

Summary

The decision about when to start dialysis for end-stage kidney disease (ESKD) is complex and is influenced by many factors. ESKD-related symptoms and signs are the most common indications for dialysis initiation. Creatinine-based formulae to estimate glomerular filtration rate (GFR) are inaccurate in patients with ESKD and, thus, the decision to start dialysis should not be based solely on estimated GFR (eGFR).
Early dialysis initiation (ie, at an eGFR > 10 mL/min/1.73 m²) is not associated with a morbidity and mortality benefit, as shown in the Initiating Dialysis Early and Late (IDEAL) study. This observation has been incorporated into the latest guidelines, which place greater emphasis on the assessment of patients’ symptoms and signs rather than eGFR. It is suggested that in asymptomatic patients with stage 5 chronic kidney disease, dialysis may be safely delayed until the eGFR is at least as low as 5–7 mL/min/1.73 m² if there is careful clinical follow-up and adequate patient education.
The decision on when to start dialysis is even more challenging in older patients. Due to their comorbidities and frailty, dialysis initiation may be associated with worse outcomes and quality of life. Therefore, the decision to start dialysis in these patients should be carefully weighed against its risks, and conservative care should be considered in appropriate cases.
To optimise the decision-making process for dialysis initiation, patients need to be referred to a nephrologist in a timely fashion to allow adequate pre-dialysis care and planning. Dialysis initiation and its timing should be a shared decision between physician, patients and family members, and should be tailored to the individual patient’s needs.

University of Sydney, Sydney, NSW

Correspondence: titi.chen@sydney.edu.au

Competing interests:

No relevant disclosures.

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Narrative review

Contemporary approaches to the prevention and management of paediatric obesity: an Australian focus

Seema Mihrshahi, Megan L Gow and Louise A Baur

Med J Aust 2018; 209 (6): . || doi: 10.5694/mja18.00140
Published online: 17 September 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Nutritional and metabolic diseases

Environment and public health

Summary

Of the 34 member countries of the Organisation for Economic Co-operation and Development, obesity prevalence is highest in the United States, with Australia ranking fifth for girls and eighth for boys. Curbing the problem is achievable and can be realised through a combination of smart governance across many sectors, community initiatives, the support of individual efforts, and clinical leadership.
At 5 years of age, one in five Australian children are already affected by overweight or obesity; obesity prevention strategies must therefore start before this age. There is strong evidence that reducing screen time and promoting breastfeeding in 0–2-year-olds are effective interventions in the early years.
The main behavioural risk factors for obesity are overconsumption of energy-dense, nutrient-poor foods and a lack of physical activity. Emerging evidence suggests poor sleep quality and duration and high amounts of sedentary time also play a role.
Systems-based policy actions may change long term obesity prevalence in children by targeting the food environment through nutrition labelling, healthy foods in schools, restricted unhealthy food marketing to children, and fiscal policies to reduce consumption of harmful foods and sugar-sweetened beverages.
Macro-environmental factors influence obesity risk. Public transport policy and the built environment (proximity to parks, bike paths, green space, schools and shops) influence play time spent outdoors, walking and cycling. Greater access to parks and playgrounds and active commuting are associated with lower body mass index.
Australian interventions have largely employed individual level approaches. These are important, but of limited effectiveness unless priority is also given to policies that reduce obesity-conducive environments.
Clinicians can provide anticipatory guidance to support healthy weight and weight-related behaviours, including weight monitoring, early feeding and children’s diets, physical activity opportunities, and limited sedentary and screen time.
Investigations in children with obesity usually include liver function tests and measuring fasting glucose, lipid and possibly insulin levels. As obesity can be associated with micronutrient deficiencies, it may be prudent to check full blood count and iron, vitamin B12 and vitamin D levels. Endocrinological assessment is usually not needed. Second line investigations may include liver ultrasound, oral glucose tolerance testing and sleep study.
Traditional treatment of child and adolescent obesity has focused on family-based, multicomponent (diet, physical activity and behaviour change) interventions, although these lead to small and often short term weight reductions (mean, − 1.45 kg; 95% CI, 1.88 to − 1.02). Nevertheless, these principles remain core interventions in children and adolescents with obesity.
A very low energy diet should be considered in adolescents with severe obesity or obesity-related comorbidities, and for adolescents who have not achieved weight loss following a more conventional dietary approach.
Pharmacotherapy confers only small reductions in weight; for example, effect size for metformin is − 3.90 kg (95% CI, − 5.86 to − 1.94).
Bariatric surgery should be considered in adolescents over 15 years of age with severe obesity (body mass index > 40 kg/m², or > 35 kg/m² in the presence of severe complications).

1 University of Sydney, Sydney, NSW
2 NHMRC Centre of Research Excellence in the Early Prevention of Obesity in Childhood, Sydney, NSW
3 The Children's Hospital at Westmead, Sydney, NSW

Correspondence: Louise.baur@health.nsw.gov.au

Competing interests:

No relevant disclosures.

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Research

Disparity of access to kidney transplantation by Indigenous and non-Indigenous Australians

Namrata Khanal, Paul D Lawton, Alan Cass and Stephen P McDonald

Med J Aust 2018; 209 (6): . || doi: 10.5694/mja18.00304
Published online: 17 September 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Urologic diseases

Indigenous health

Abstract

Objective: To compare the likelihood of Indigenous and non-Indigenous Australians being placed on the waiting list for transplantation of a kidney from a deceased donor; to compare the subsequent likelihood of transplantation.

Design, setting and participants: Observational cohort study; analysis of data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry for patients aged 18–60 years at the start of renal replacement therapy, who commenced renal replacement therapy in Australia between 28 June 2006 and 31 December 2016.

Main outcome measures: Time to wait-listing; time to kidney transplantation after wait-listing.

Results: 10 839 patients met the inclusion criteria, of whom 2039 (19%) were Indigenous Australians; 217 Indigenous and 3829 non-Indigenous patients were active on the waiting list at least once during the study period. The hazard ratio (HR) for wait-listing (Indigenous v non-Indigenous patients, adjusted for patient- and disease-related factors) in the first year of renal replacement therapy varied with age and remoteness (range, 0.11 [95% CI, 0.07–0.15] to 0.36 [95% CI, 0.16–0.56]); in subsequent years the adjusted HR was 0.90 (95% CI, 0.50–1.6). The adjusted HR for transplantation during the first year of wait-listing did not differ significantly from 1.0; for subsequent years of wait-listing, however, the adjusted HR was 0.40 (95% CI, 0.29–0.55).

Conclusion: Disparities between Indigenous and non-Indigenous patients with end-stage kidney disease in access to kidney transplantation are not explained by patient- or disease-related factors. Changes in policy and practice are needed to reduce these differences.

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1 University of Adelaide, Adelaide, SA
2 Central and Northern Adelaide Renal and Transplantation Services, Royal Adelaide Hospital, Adelaide, SA
3 Menzies School of Health Research, Charles Darwin University, Darwin, NT
4 Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), Adelaide, SA

Correspondence: namrata@anzdata.org.au

Competing interests:

No relevant disclosures.

1. Stewart JH, McCredie MR, McDonald SP. The incidence of treated end-stage renal disease in New Zealand Maori and Pacific Island people and in Indigenous Australians. Nephrol Dial Transplant 2004; 19: 678-685.
2. Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples: 2015 (AIHW Cat. No. IHW 147). Canberra: AIHW, 2015. https://www.aihw.gov.au/reports/indigenous-health-welfare/indigenous-health-welfare-2015/contents/health-disability-key-points (viewed July 2018).
3. Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 1999; 341: 1725-1730.
4. Rabbat CG, Thorpe KE, Russell JD, Churchill DN. Comparison of mortality risk for dialysis patients and cadaveric first renal transplant recipients in Ontario, Canada. J Am Soc Nephrol 2000; 11: 917-922.
5. Cass A, Cunningham J, Snelling P, et al. Renal transplantation for Indigenous Australians: identifying the barriers to equitable access. Ethn Health 2003; 8: 111-119.
6. Yeates KE, Cass A, Sequist TD, et al. Indigenous people in Australia, Canada, New Zealand and the United States are less likely to receive renal transplantation. Kidney Int 2009; 76: 659-664.
7. Lindholt JS, Juul S, Fasting H, Henneberg EW. Screening for abdominal aortic aneurysms: single centre randomised controlled trial. BMJ 2005; 330: 750.
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9. Sen S, Tom M, Geetha M, Satheesan B. Estimating unknown heterogeneity in head and neck cancer survival: a parametric shared frailty approach. Electronic Journal of Applied Statistical Analysis 2017; 10: 82-92.
10. The Transplantation Society of Australia and New Zealand. Clinical guidelines for organ transplantation from deceased donors. Version 1.1. May 2017. https://www.tsanz.com.au/organallocationguidelines/documents/ClinicalGuidelinesV1.1May2017.pdf (viewed July 2018).
11. National Health and Medical Research Council. Ethical guidelines for organ transportation from deceased donors. Canberra: National Health and Medical Research Council. Apr 2016. https://www.nhmrc.gov.au/_files_nhmrc/file/publications/16113_nhmrc_ethical_guidelines_fot_web_0.pdf (viewed July 2018).
12. Alexander G, Sehgal A. Barriers to cadaveric renal transplantation among blacks, women, and the poor. JAMA 1998; 280: 1148-1152.
13. Anderson K, Cunningham J, Devitt J, Cass A. The IMPAKT study: using qualitative research to explore the impact of end-stage kidney disease and its treatments on aboriginal and Torres Strait Islander Australians. Kidney Int Suppl 2013; 3: 223-226.
14. Cass A, Lowell A, Christie M, et al. Sharing the true stories: improving communication between Aboriginal patients and healthcare workers. Med J Aust 2002; 176: 466-470. <MJA full text>
15. Devitt J, Anderson K, Cunningham J, et al. Difficult conversations: Australian Indigenous patients’ views on kidney transplantation. BMC Nephrol 2017; 18: 310.
16. Cass A, Feyer A, Brown A, et al. Central Australia Renal Study. Canberra: Australian Department of Health and Ageing; 2011. http://www.health.gov.au/internet/main/publishing.nsf/content/B442C16562A8AC37CA257BF0001C9649/$File/Final%20Report%20Central%20Australia%20Renal%20Study.pdf (viewed July 2018).
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18. Barraclough KA, Grace BS, Lawton P, McDonald SP. Residential location and kidney transplant outcomes in indigenous compared with nonindigenous Australians. Transplantation 2016; 100: 2168-2176.
19. Kotwal S, Webster AC, Cass A, Gallagher M. Comorbidity recording and predictive power of comorbidities in the Australia and New Zealand dialysis and transplant registry compared with administrative data: 2000-2010. Nephrology (Carlton) 2016; 21: 930-937.

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Perspectives

Kidney donation and transplantation in Australia: more than a supply and demand equation

Jeremy R Chapman and John Kanellis

Med J Aust 2018; 209 (6): . || doi: 10.5694/mja18.00617
Published online: 17 September 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Surgical procedures, operative

Urologic diseases

Social determinants of health

Health services administration

The Australian organ allocation system relies on equity and maximising effectiveness, but these are sometimes difficult to reconcile

Donated kidneys are scarce and valuable, generously supplied by living donors or altruistically after death. Access to the Australian kidney transplant waiting list requires individuals with end-stage kidney disease to be eligible for Medicare and accepted by a transplant program through meeting the medium to long term life expectancy eligibility criteria from the Transplantation Society of Australia and New Zealand (TSANZ).1 There are state by state and transplant unit specific approaches to listing based on geography and population variability.2 The current overall Australian 5-year kidney transplant recipient survival rate is about 90%, with 5-year kidney survival at about 80%,3 as reported through the Australia and New Zealand Dialysis and Transplant Registry.4 There is, on average, a five- to ten-fold reduction in mortality for patients who have received a kidney transplant compared with those who remain on dialysis, explaining the continued demand for kidneys for transplantation.5

1 Westmead Hospital, Sydney, NSW
2 Monash Medical Centre, Melbourne, VIC

Correspondence: Jeremy.Chapman@health.nsw.gov.au

Competing interests:

No relevant disclosures.

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3. Australia and New Zealand Dialysis and Transplant Registry. 40th Report. Chapter 7: transplantation. Adelaide: ANZDATA; 2018. http://www.anzdata.org.au/anzdata/AnzdataReport/40thReport/c07_transplant_2016_v1.0_20180509.pdf (viewed Aug 2018).
4. McDonald SP. Australia and New Zealand Dialysis and Transplant Registry. Kidney Int Suppl (2011) 2015; 5: 39-44.
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Research

Sepsis incidence and mortality are underestimated in Australian intensive care unit administrative data

Manon Heldens, Marinelle Schout, Naomi E Hammond, Frances Bass, Anthony Delaney and Simon R Finfer

Med J Aust 2018; 209 (6): . || doi: 10.5694/mja18.00168
Published online: 10 September 2018

ARTICLE
AUTHORS
REFERENCES

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Infectious diseases

Emergency medicine

Abstract

Objectives: To compare estimates of the incidence and mortality of sepsis and septic shock among patients in Australian intensive care units (ICUs) according to clinical diagnoses or binational intensive care database (ANZICS CORE) methodology.

Design, setting, participants: Prospective inception cohort study (3-month inception period, 1 October – 31 December 2016, with 60-day follow-up); daily screening of all patients in a tertiary hospital 60-bed multidisciplinary ICU.

Main outcomes: Diagnoses of sepsis and septic shock according to clinical criteria and database criteria; in-hospital mortality (censored at 60 days).

Results: Of 864 patients admitted to the ICU, 146 (16.9%) were diagnosed with sepsis by clinical criteria and 98 (11%) according to the database definition (P < 0.001); the sensitivity of the database criteria for sepsis was 52%, the specificity 97%. Forty-nine patients (5.7%) were diagnosed with septic shock by clinical criteria and 83 patients (9.6%) with the database definition (P < 0.001); the sensitivity of the database criteria for septic shock was 65%, the specificity 94%. In-hospital mortality of patients diagnosed with sepsis was greater in the clinical diagnosis group (39/146, 27%) than in the database group (17/98, 17%; P = 0.12); for septic shock, mortality was significantly higher in the database group (18/49, 37%) than in the clinical diagnosis group (13/83, 16%; P = 0.006).

Conclusions: When compared with the reference standard — prospective clinical diagnosis — ANZICS CORE database criteria significantly underestimate the incidence of sepsis and overestimate the incidence of septic shock, and also result in lower estimated hospital mortality rates for each condition.

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1 Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
2 Royal North Shore Hospital, Sydney, NSW
3 Maasziekenhuis Pantein, Beugen, The Netherlands
4 The George Institute for Global Health, Sydney, NSW
5 Northern Clinical School, University of Sydney, Sydney, NSW

Correspondence: heldensmanon@gmail.com

Acknowledgements:

We acknowledge the support of the Royal North Shore Hospital intensive care unit staff. Manon Heldens received funding from the Radboud Honours program “Beyond the Frontiers”, Radboud University, Nijmegen, The Netherlands. Simon Finfer is supported by a National Health and Medical Research Committee Practitioner Fellowship.

Competing interests:

No relevant disclosures.

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All colonoscopies are not created equal: why Australia now has a clinical care standard for colonoscopy

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