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    Adding kindness at handover to improve our collegiality: the K-ISBAR tool

    David J Brewster and Bruce P Waxman
    Med J Aust 2018; 209 (11): . || doi: 10.5694/mja18.00755
    Published online: 10 December 2018

    Much has been written recently about the mental health of the Australian medical workforce, with doctors being burned out, bullied, harassed and mentally unwell.1,2 Why are doctors so unkind to each other? What has happened to collegiality? While we are from different medical backgrounds, we are united in the belief that it is time for change; time for a united response from the Australian medical profession focusing on collegiality, using kindness and understanding as the catalyst and clinical handover as the opportunity.


    • 1 Cabrini Clinical School, Monash University, Melbourne, VIC
    • 2 Cabrini Health, Melbourne, VIC
    • 3 School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC


    Correspondence: dbrewster@cabrini.com.au
    Acknowledgements: 

    We thank Dr Malcolm Clark for his contribution to an earlier draft of this article.

    Competing interests:

    No relevant disclosures.

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      From the curious case of Patient K to TOP GEAR and Bond

      Nicholas J Talley AC
      Med J Aust 2018; 209 (11): . || doi: 10.5694/mja18.01086
      Published online: 10 December 2018

      Celebrating a great year for the MJA with our 2018 holiday issue

      Welcome to the traditional summer edition of the MJA! In place of all the ground-breaking research, expert reviews, meta-analyses, and penetrating perspectives we publish throughout the year, we present a fascinating potpourri of the amusing and interesting articles and commentaries we have received as entries for our annual Christmas competition, before reviewing the best research we published during 2018.

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      • Editor-in-Chief, the Medical Journal of Australia, on behalf of the MJA Editorial team


      Correspondence: ntalley@mja.com.au
      Competing interests:

      No relevant disclosures for this article. A complete list of my conflict of interest disclosures is found at

      • 1. Wilson N, Tucker D, Heath D, Scarborough P. License to swill: James Bond’s drinking over six decades. Med J Aust 2018; 209: 495-500.
      • 2. Ellis M, Sun M, Wood M, Chan WO. The Observational Physician and surGEon Automobile Response (TOP GEAR) survey. Med J Aust 2018; 209: 503-505.
      • 3. Teo SS, Manivel V. C-ABC: cash before care in a private emergency department? Med J Aust 2018; 209: 509-510.
      • 4. Bauman AE, Blazek K, Reece L, Bellew W. The emergence and characteristics of the Australian Mamil. Med J Aust 2018; 209; 490-494.
      • 5. Elisha R. The curious case of patient K. Med J Aust 2018; 209: 501-502.
      • 6. Cairns R, Brown JA, Dawson AH, et al. Carols by glow sticks: a retrospective analysis of Poisons Information Centre data. Med J Aust 2018; 209: 505-508.
      • 7. Prince SA. The Christmas e-list (an ode to big data). Med J Aust 2018; 209: 510.
      • 8. Tong EY, Roman CP, Mitra B, et al. Reducing medication errors in hospital discharge summaries: a randomised controlled trial. Med J Aust 2017; 206: 36-39. <MJA full text>
      • 9. Chanchlani S, Chang D, Ong JSL, Anwar A. The value of peer mentoring for the psychosocial wellbeing of junior doctors: a randomised controlled study. Med J Aust 2018; 209: 401-405. <MJA full text>
      • 10. Khan E, Brieger D, Amerena J, et al. Differences in management and outcomes for men and women with ST-elevation myocardial infarction. Med J Aust 2018; 209: 118-123. <MJA full text>
      • 11. Huynh Q, Negishi K, De Pasquale C, et al. Effects of post-discharge management on rates of early re-admission and death after hospitalisation for heart failure. Med J Aust 2018; 208: 485-491. <MJA full text>
      • 12. Davis K, Remenyi B, Draper ADK, et al. Rheumatic heart disease in Timor-Leste school students: an echocardiography-based prevalence study. Med J Aust 2018; 208: 303-307. <MJA full text>
      • 13. Zbrojkiewicz D, Vertullo C, Grayson JE. Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000–2015. Med J Aust 2018; 208: 354-358. <MJA full text>
      • 14. Cheney K, Farber R, Barratt AL, et al. Population attributable fractions of perinatal outcomes for nulliparous women associated with overweight and obesity, 1990–2014. Med J Aust 2018; 208: 119-125. <MJA full text>
      • 15. Davies SJ, Lum JAG, Skouteris H, et al. Cognitive impairment during pregnancy: a meta-analysis. Med J Aust 2018; 208: 35-40. <MJA full text>
      • 16. Hong TP, Gow PJ, Fink M, et al. Surveillance improves survival of patients with hepatocellular carcinoma: a prospective population-based study. Med J Aust 2018; 209: 348-354. <MJA full text>
      • 17. Evans MA, Millar JL, Earnest A, et al. Active surveillance of men with low risk prostate cancer: evidence from the Prostate Cancer Outcomes Registry–Victoria. Med J Aust 2018; 208: 439-443. <MJA full text>
      • 18. Curchin DJ, Harris VR, McCormack CJ, Smith SD. Changing trends in the incidence of invasive melanoma in Victoria, 1985–2015. Med J Aust 2018; 208: 265-269. <MJA full text>

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        Methods of melanoma detection and of skin monitoring for individuals at high risk of melanoma: new Australian clinical practice guidelines

        Nikki R Adler, John W Kelly, Pascale Guitera, Scott W Menzies, Alex J Chamberlain, Paul Fishburn, Alison E Button‐Sloan, Clinton Heal, H Peter Soyer and John F Thompson
        Med J Aust 2019; 210 (1): . || doi: 10.5694/mja2.12033
        Published online: 2 December 2018

        Abstract

        Introduction: The evidence‐based national clinical practice guidelines for the management of cutaneous melanoma published in 2008 are currently being updated. This article summarises the findings from multiple chapters of the guidelines on different methods of melanoma detection and of monitoring the skin for patients at high risk of melanoma. Early detection of melanoma is critical, as thinner tumours are associated with enhanced survival; therefore, strategies to improve early detection are important to reduce melanoma‐related mortality.

        Main recommendations:

        • Clinicians who perform skin examinations for the purpose of detecting skin cancer should be trained in and use dermoscopy.
        • The use of short term sequential digital dermoscopy imaging to detect melanomas that lack dermoscopic features of melanoma is recommended to assess individual melanocytic lesions of concern.
        • The use of long term sequential digital dermoscopy imaging to detect melanomas that lack dermoscopic features of melanoma is recommended to assess individual or multiple melanocytic lesions for routine surveillance of high risk patients.
        • The use of total body photography should be considered in managing patients at increased risk for melanoma, particularly those with high naevus counts and dysplastic naevi.
        • There is insufficient evidence to recommend the routine use of automated instruments for the clinical diagnosis of primary melanoma.

         

        Management overview: Determining the relative indications for each diagnostic method and how each method should be introduced into the surveillance of a patient requires careful consideration and an individualised approach.


        • 1 Victorian Melanoma Service, Alfred Hospital, Melbourne, VIC
        • 2 Armadale Dermatology, Melbourne, VIC
        • 3 Melanoma Institute Australia, Sydney, NSW
        • 4 University of Sydney, Sydney, NSW
        • 5 Royal Prince Alfred Hospital, Sydney, NSW
        • 6 Sydney Melanoma Diagnostic Centre, University of Sydney, Sydney, NSW
        • 7 Victorian Melanoma Service, Alfred Health, Melbourne, VIC
        • 8 Glenferrie Dermatology, Melbourne, VIC
        • 9 Norwest Skin Cancer Centre, Sydney, NSW
        • 10 Melanoma Patients Australia, Brisbane, QLD
        • 11 MelanomaWA, Perth, WA
        • 12 Dermatology Research Centre, Diamantina Institute, University of Queensland, Brisbane, QLD
        • 13 Princess Alexandra Hospital, Brisbane, QLD


        Correspondence: nikki.adler@monash.edu
        Acknowledgements: 

        The development of the new Australian clinical practice guidelines for the diagnosis and management of melanoma was funded by Cancer Council Australia and the Melanoma Institute Australia, with additional support from the Skin Cancer College Australasia and the Australasian College of Dermatologists. Nikki Adler is supported by a Research Training Program stipend scholarship, Monash University. H Peter Soyer has an NHMRC Practitioner Fellowship. John Thompson is supported by the Melanoma Foundation at the University of Sydney.

        Competing interests:

        No relevant disclosures.

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        • 27. van der Rhee JI, Bergman W, Kukutsch NA. Impact of dermoscopy on the management of high‐risk patients from melanoma families: a prospective study. Acta Derm Venereol 2011; 91: 428–431.
        • 28. Kittler H, Guitera P, Riedl E, et al. Identification of clinically featureless incipient melanoma using sequential dermoscopy imaging. Arch Dermatol 2006; 142: 1113–1119.
        • 29. Haenssle HA, Krueger U, Vente C, et al. Results from an observational trial: digital epiluminescence microscopy follow‐up of atypical nevi increases the sensitivity and the chance of success of conventional dermoscopy in detecting melanoma. J Invest Dermatol 2006; 126: 980–985.
        • 30. Altamura D, Avramidis M, Menzies SW. Assessment of the optimal interval for and sensitivity of short‐term sequential digital dermoscopy monitoring for the diagnosis of melanoma. Arch Dermatol 2008; 144: 502–506.
        • 31. Robinson JK, Nickoloff BJ. Digital epiluminescence microscopy monitoring of high‐risk patients. Arch Dermatol 2004; 140: 49–56.
        • 32. Menzies SW, Gutenev A, Avramidis M, et al. Short‐term digital surface microscopic monitoring of atypical or changing melanocytic lesions. Arch Dermatol 2001; 137: 1583–1589.
        • 33. Salerni G, Terán T, Alonso C, Fernández‐Bussy R. The role of dermoscopy and digital dermoscopy follow‐up in the clinical diagnosis of melanoma: clinical and dermoscopic features of 99 consecutive primary melanomas. Dermatol Pract Concept 2014; 4: 39–46.
        • 34. Moloney FJ, Guitera P, Coates E, et al. Detection of primary melanoma in individuals at extreme high risk: a prospective 5‐year follow‐up study. JAMA Dermatol 2014; 150: 819–827.
        • 35. Salerni G, Carrera C, Lovatto L, et al. Characterization of 1152 lesions excised over 10 years using total‐body photography and digital dermatoscopy in the surveillance of patients at high risk for melanoma. J Am Acad Dermatol 2012; 67: 836–845.
        • 36. Tromme I, Sacré L, Hammouch F, et al. Availability of digital dermoscopy in daily practice dramatically reduces the number of excised melanocytic lesions: results from an observational study. Br J Dermatol 2012; 167: 778–786.
        • 37. Schiffner R, Schiffner‐Rohe J, Landthaler M, Stolz W. Long‐term dermoscopic follow‐up of melanocytic naevi: clinical outcome and patient compliance. Br J Dermatol 2003; 149: 79–86.
        • 38. Haenssle HA, Korpas B, Hansen‐Hagge C, et al. Selection of patients for long‐term surveillance with digital dermoscopy by assessment of melanoma risk factors. Arch Dermatol 2010; 146: 257–264.
        • 39. Fuller SR, Bowen GM, Tanner B, et al. Digital dermoscopic monitoring of atypical nevi in patients at risk for melanoma. Dermatol Surg 2007; 33: 1198–1206.
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        • 42. Kittler H, Marghoob AA, Argenziano G, et al. Standardization of terminology in dermoscopy/dermatoscopy: results of the third consensus conference of the International Society of Dermoscopy. J Am Acad Dermatol 2016; 74: 1093–1106.
        • 43. Argenziano G, Giacomel J, Zalaudek I, et al. A clinico‐dermoscopic approach for skin cancer screening: recommendations involving a survey of the International Dermoscopy Society. Dermatol Clin 2013; 31: 525–534.
        • 44. Kittler H, Pehamberger H, Wolff K, Binder M. Diagnostic accuracy of dermoscopy. Lancet Oncol 2002; 3: 159–165.
        • 45. Bafounta ML, Beauchet A, Aegerter P, Saiag P. Is dermoscopy (epiluminescence microscopy) useful for the diagnosis of melanoma? Results of a meta‐analysis using techniques adapted to the evaluation of diagnostic tests. Arch Dermatol 2001; 137: 1343–1350.
        • 46. Haenssle HA, Hoffmann S, Holzkamp R, et al. Melanoma thickness: the role of patients’ characteristics, risk indicators and patterns of diagnosis. J Eur Acad Dermatol Venereol 2015; 29: 102–108.
        • 47. Westerhoff K, McCarthy WH, Menzies SW. Increase in the sensitivity for melanoma diagnosis by primary care physicians using skin surface microscopy. Br J Dermatol 2000; 143: 1016–1020.
        • 48. Dolianitis C, Kelly J, Wolfe R, Simpson P. Comparative performance of 4 dermoscopic algorithms by nonexperts for the diagnosis of melanocytic lesions. Arch Dermatol 2005; 141: 1008–1014.
        • 49. Binder M, Puespoeck‐Schwarz M, Steiner A, et al. Epiluminescence microscopy of small pigmented skin lesions: short‐term formal training improves the diagnostic performance of dermatologists. J Am Acad Dermatol 1997; 36: 197–202.
        • 50. Salerni G, Terán T, Puig S, et al. Meta‐analysis of digital dermoscopy follow‐up of melanocytic skin lesions: a study on behalf of the International Dermoscopy Society. J Eur Acad Dermatol Venereol 2013; 27: 805–814.
        • 51. Kittler H, Pehamberger H, Wolff K, Binder M. Follow‐up of melanocytic skin lesions with digital epiluminescence microscopy: patterns of modifications observed in early melanoma, atypical nevi, and common nevi. J Am Acad Dermatol 2000; 43: 467–476.
        • 52. Feit NE, Dusza SW, Marghoob AA. Melanomas detected with the aid of total cutaneous photography. Br J Dermatol 2004; 150: 706–714.
        • 53. Kelly JW, Yeatman JM, Regalia C, et al. A high incidence of melanoma found in patients with multiple dysplastic naevi by photographic surveillance. Med J Aust 1997; 167: 191–194. https://www.mja.com.au/journal/1997/167/4/high-incidence-melanoma-found-patients-multiple-dysplastic-naevi-photographic
        • 54. Banky JP, Kelly JW, English DR, et al. Incidence of new and changed nevi and melanomas detected using baseline images and dermoscopy in patients at high risk for melanoma. Arch Dermatol 2005; 141: 998–1006.
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        • 58. Guitera P, Pellacani G, Crotty KA, et al. The impact of in vivo reflectance confocal microscopy on the diagnostic accuracy of lentigo maligna and equivocal pigmented and nonpigmented macules of the face. J Invest Dermatol 2010; 130: 2080–2091.
        • 59. Borsari S, Pampena R, Lallas A, et al. Clinical indications for use of reflectance confocal microscopy for skin cancer diagnosis. JAMA Dermatol 2016; 152: 1093–1098.
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        • 61. Guitera P, Menzies SW, Argenziano G, et al. Dermoscopy and in vivo confocal microscopy are complementary techniques for diagnosis of difficult amelanotic and light‐coloured skin lesions. Br J Dermatol 2016; 175: 1311–1319.
        • 62. Alarcon I, Carrera C, Palou J, et al. Impact of in vivo reflectance confocal microscopy on the number needed to treat melanoma in doubtful lesions. Br J Dermatol 2014; 170: 802–808.
        • 63. Ferrari B, Pupelli G, Farnetani F, et al. Dermoscopic difficult lesions: an objective evaluation of reflectance confocal microscopy impact for accurate diagnosis. J Eur Acad Dermatol Venereol 2015; 29: 1135–1140.
        • 64. Stanganelli I, Longo C, Mazzoni L, et al. Integration of reflectance confocal microscopy in sequential dermoscopy follow‐up improves melanoma detection accuracy. Br J Dermatol 2015; 172: 365–371.
        • 65. Watts CG, Cust AE, Menzies SW, et al. Cost‐effectiveness of skin surveillance through a specialized clinic for patients at high risk of melanoma. J Clin Oncol 2017; 35: 63–71.
        • 66. Janda M, Loescher LJ, Soyer H. Enhanced skin self‐examination: a novel approach to skin cancer monitoring and follow‐up. JAMA Dermatol 2013; 149: 231–236.
        • 67. Secker LJ, Bergman W, Kukutsch NA. Total body photography as an aid to skin self‐examination: a patient's perspective. Acta Derm Venereol 2016; 96: 186–190.

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          Forty years of “Waltzing Matilda”: the history of the multichannel cochlear implant

          Joyce PK Ho, Hannah North and Narinder P Singh
          Med J Aust 2018; 209 (11): . || doi: 10.5694/mja18.00365
          Published online: 3 December 2018

          The fascinating history of the multichannel cochlear implant and its inventor, Professor Graeme Clark

          A cochlear implant is a surgically implanted device for converting sounds into an electrical current that directly stimulates the cochlear nerve.1 It consists of external (microphone, speech processor, transmitter) and internal components (receiver/stimulator, electrode array in the cochlea) and can be implanted in both children and adults.


          • 1 Westmead Hospital, Sydney, NSW
          • 2 Westmead Clinical School, University of Sydney, Sydney, NSW
          • 3 Ear Nose & Throat Sydney, Sydney, NSW


          Acknowledgements: 

          All images provided courtesy of Cochlear Limited.

          Competing interests:

          No relevant disclosures.

          • 1. Mudry A, Mills M. The early history of the cochlear implant: a retrospective. JAMA Otolaryngol Head Neck Surg 2013; 139: 446-453.
          • 2. National Institute on Deafness and Other Communication Disorders (NIDCD). Cochlear implants [webpage]. Updated Mar 2017. https://www.nidcd.nih.gov/health/cochlear-implants (viewed Dec 2017).
          • 3. Sparrow R. Defending deaf culture: the case of cochlear implants. J Polit Philos 2005; 13: 135-152.
          • 4. Simmons FB. Electrical stimulation of the auditory nerve in man. Arch Otolaryngol 1966; 84: 2-54.
          • 5. Seitz PR. French origins of the cochlear implant. Cochlear Implants Int 2002; 3: 77-86.
          • 6. O’Leary S. Professor Graeme Clark, otolaryngologist. Australia. Australian Academy of Science; 2011. https://www.science.org.au/learning/general-audience/history/interviews-australian-scientists/professor-graeme-clark (viewed Dec 2017).
          • 7. Clark GM. A hearing prosthesis for severe perceptive deafness: experimental studies. J Laryngol Otol 1973; 87: 929-945.
          • 8. Clark GM. Responses of cells in the superior olivary complex of the cat to electrical stimulation of the auditory nerve. Exp Neurol 1969; 24: 124-136.
          • 9. Clark GM, Hallwoeth RJ, Zdanius K. A cochlear implant electrode. J Laryngol Otol 1975; 89: 787-792.
          • 10. Clark GM. Personal reflections on the multichannel cochlear implant and a view of the future. J Rehabil Res Dev 2008; 45: 651-693.
          • 11. Clark GM, Pyman, BC, Bailey QR. The surgery for multiple-electrode cochlear implantations. J Laryngol Otol 1979; 93: 215-223.
          • 12. Tong YC, Black RC, Clark GM, et al. A preliminary report on a multiple-channel cochlear implant operation. J Laryngol Otol 1979; 93: 679-695.

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            The MJA–Lancet Countdown on health and climate change: Australian policy inaction threatens lives

            Ying Zhang, Paul J Beggs, Hilary Bambrick, Helen L Berry, Martina K Linnenluecke, Stefan Trueck, Robyn Alders, Peng Bi, Sinead M Boylan, Donna Green, Yuming Guo, Ivan C Hanigan, Elizabeth G Hanna, Arunima Malik, Geoffrey G Morgan, Mark Stevenson, Shilu Tong, Nick Watts and Anthony G Capon
            Med J Aust 2018; 209 (11): . || doi: 10.5694/mja18.00789
            Published online: 29 November 2018

            Summary

             

            • Climate plays an important role in human health and it is well established that climate change can have very significant impacts in this regard. In partnership with The Lancet and the MJA, we present the inaugural Australian Countdown assessment of progress on climate change and health.
            • This comprehensive assessment examines 41 indicators across five broad sections: climate change impacts, exposures and vulnerability; adaptation, planning and resilience for health; mitigation actions and health co-benefits; economics and finance; and public and political engagement.
            • These indicators and the methods used for each are largely consistent with those of the Lancet Countdown global assessment published in October 2017, but with an Australian focus. Significant developments include the addition of a new indicator on mental health.
            • Overall, we find that Australia is vulnerable to the impacts of climate change on health, and that policy inaction in this regard threatens Australian lives. In a number of respects, Australia has gone backwards and now lags behind other high income countries such as Germany and the United Kingdom. Examples include the persistence of a very high carbon-intensive energy system in Australia, and its slow transition to renewables and low carbon electricity generation. However, we also find some examples of good progress, such as heatwave response planning.
            • Given the overall poor state of progress on climate change and health in Australia, this country now has an enormous opportunity to take action and protect human health and lives. Australia has the technical knowhow and intellect to do this, and our annual updates of this assessment will track Australia’s engagement with and progress on this vitally important issue.

             

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            • 1 School of Public Health, University of Sydney, Sydney, NSW
            • 2 Department of Environmental Sciences, Macquarie University, Sydney, NSW
            • 3 School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD
            • 4 Department of Applied Finance, Macquarie University, Sydney, NSW
            • 5 International Rural Poultry Centre, Kyeema Foundation, Brisbane, QLD
            • 6 Centre for Global Health Security, Chatham House, London, UK
            • 7 School of Public Health, University of Adelaide, Adelaide, SA
            • 8 Climate Change Research Centre, ARC Centre of Excellence for Climate Extremes, University of New South Wales, Sydney, NSW
            • 9 Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC
            • 10 University Centre for Rural Health, University of Sydney, Sydney, NSW
            • 11 Climate Change Institute, Australian National University, Canberra, ACT
            • 12 School of Physics, University of Sydney, Sydney, NSW
            • 13 University Centre for Rural Health, University of Sydney, Lismore, NSW
            • 14 Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC
            • 15 Department of Clinical Epidemiology and Biostatistics, Shanghai Jiao Tong University, Shanghai, China
            • 16 Institute of Environment and Population Health, Anhui Medical University, Hefei, China
            • 17 Institute of Global Health, University College London, London, UK


            Correspondence: ying.zhang@sydney.edu.au
            Acknowledgements: 

            We thank Dr Elizabeth Ebert (Australian Bureau of Meteorology) for contributing indicator 2.4 (Climate information services for health). We also thank Dr Luke Knibbs (University of Queensland) who provided assistance with the PM monitor data for indicator 3.5.1 (Exposure to air pollution in cities). Indicator 3.9 (Health care sector emissions) builds on Malik et al ( 2018; 2: e27–e35) and we would like to acknowledge the co-authors of that publication: Prof Manfred Lenzen, Dr Forbes McGain and Scott McAlister. We would also like to acknowledge Fabiola Barba Ponce (Macquarie University).

            Competing interests:

            Anthony Capon directs the human health and social impacts research node of the NSW Adaptation Research Hub.

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              Reducing cardiovascular risk in people with diabetes and kidney disease

              Brendon L Neuen and Vlado Perkovic
              Med J Aust 2018; 209 (10): . || doi: 10.5694/mja18.00929
              Published online: 19 November 2018

              We need to move beyond managing end organ complications to reducing cardio-renal risk across the spectrum of kidney function

              Type 2 diabetes mellitus is one of the greatest challenges facing the Australian health care system. The number of Australians living with diabetes has tripled over the past 25 years, and by 2025 it is expected that 3 million adults will have been diagnosed with the disease, one of the most rapid rises for any chronic condition in Australia.1


              • The George Institute for Global Health, Sydney, NSW


              Acknowledgements: 

              Brendon Neuen is funded by a John Chalmers PhD Scholarship from the George Institute for Global Health and a University Postgraduate Award from UNSW Sydney. Vlado Perkovic receives research support from the National Health and Medical Research Council (Senior Research Fellowship and Program Grant).

              Competing interests:

              The George Institute for Global Health provides contract research services to Janssen for trials of sodium/glucose cotransporter 2 (SGLT2) inhibitors. Brendon Neuen receives travel support from Janssen. Vlado Perkovic is the chair of a steering committee for a renal outcome study of an SGLT2 inhibitor (canagliflozin), serves on steering committees for AbbVie, Boehringer Ingelheim, GlaxoSmithKline, Janssen and Pfizer, and serves on advisory boards or speaks at scientific meetings for AbbVie, Astellas, AstraZeneca, Bayer, Baxter, Bristol-Myers Squibb, Boehringer Ingelheim, Durect, Eli Lilly, Gilead, GlaxoSmithKline, Janssen, Merck, Novartis, Novo Nordisk, Pfizer, Pharmalink, Relypsa, Roche, Sanofi, Servier and Vitae; all honoraria for these activities are paid to the George Institute for Global Health.


              • 1. Baker IDI Heart and Diabetes Institute, Diabetes Australia, Juvenile Diabetes Research Foundation. Diabetes: the silent pandemic and its impact on Australia. 2012. https://baker.edu.au/-/media/documents/impact/diabetes-the-silent-pandemic.ashx?la=en (viewed Sept 2018).
              • 2. Thomas MC, Cooper ME, Zimmet P. Changing epidemiology of type 2 diabetes mellitus and associated chronic kidney disease. Nat Rev Nephrol 2016; 12: 73-81.
              • 3. Kidney Health Australia. The economic impact of end-stage kidney disease in Australia: projections to 2020. 2010. https://kidney.org.au/cms_uploads/docs/kha-economic-impact-of-eskd-in-australia-projections-2020.pdf (viewed Sept 2018).
              • 4. Lim WH, Johnson DW, Hawley C, et al. Type 2 diabetes in patients with end-stage kidney disease: influence on cardiovascular disease-related mortality risk. Med J Aust 2018; 209: 440-446.
              • 5. Lascar N, Brown J, Pattison H, et al. Type 2 diabetes in adolescents and young adults. Lancet Diabetes Endocrinol 2018; 6: 69-80.
              • 6. Wanner C, Tonelli M. KDIGO clinical practice guideline for lipid management in CKD: summary of recommendation statements and clinical approach to the patient. Kidney Int 2014; 85: 1303-1309.
              • 7. Heerspink HJL, Ninomiya T, Zoungas S, et al. Effect of lowering blood pressure on cardiovascular events and mortality in patients on dialysis: a systematic review and meta-analysis of randomised controlled trials. Lancet 2009; 373: 1009-1015.
              • 8. Palmer SC, Di Micco L, Razavian M, et al. Effects of antiplatelet therapy on mortality and cardiovascular and bleeding outcomes in persons with chronic kidney disease: a systematic review and meta-analysis. Ann Intern Med 2012; 156: 445-459.
              • 9. O’Lone E, Viecelli AK, Craig JC, et al. Cardiovascular outcomes reported in hemodialysis trials. J Am Coll Cardiol 2018; 71: 2802-2810.
              • 10. Tong A, Manns B, Hemmelgarn B, et al. Establishing core outcome domains in hemodialysis: report of the Standardized Outcomes in Nephrology–Hemodialysis (SONG-HD) consensus workshop. Am J Kidney Dis 2017; 69: 97-107.
              • 11. American Diabetes Association. Pharmacologic approaches to glycemic treatment: standards of medical care in diabetes — 2018. Diabetes Care 2018; 41: S73-S85.
              • 12. Diabetes Canada Clinical Practice Guidelines Expert Committee; Lipscombe L, Booth G, Butalia S, et al. Pharmacologic glycemic management of type 2 diabetes in adults. Can J Diabetes 2018; 42: S88-S103.

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                Deprescribing proton pump inhibitors: why, when and how

                Peter Bytzer
                Med J Aust 2018; 209 (10): . || doi: 10.5694/mja18.00674
                Published online: 12 November 2018

                The focus should primarily be on avoiding unnecessary long term prescribing of PPIs

                For more than 25 years, proton pump inhibitors (PPIs) have been the mainstay of therapy for acid-related disorders, particularly peptic ulcer disease and gastro-oesophageal reflux disease (GORD). In recent decades, prescribing of PPIs has increased considerably around the world. According to a recent national drug utilisation study, prescribing of PPIs increased fourfold in Denmark between 2002 and 2014, with the increase particularly marked among older patients; 7% of all adults and 14% of adults over 60 were covered by PPI prescriptions.1 The increased prescribing of PPIs is driven primarily by the accumulation of existing users rather than by new users; inappropriate prescribing and long term use, rather than genuine clinical need for ulcer prophylaxis, appear to underlie the high prevalence of PPI prescribing.2 Changes to public subsidisation of PPI costs and interventions for improving adherence to guidelines and promoting the rational use of PPIs have not had a substantial influence on prescribing patterns.


                • University of Copenhagen, Køge, Denmark


                Correspondence: pmby@regionsjaelland.dk
                Competing interests:

                No relevant disclosures.

                • 1. Pottegård A, Broe A, Hallas J, et al. Use of proton-pump inhibitors among adults: a Danish nationwide drug utilization study. Therap Adv Gastroenterol 2016; 9: 671-678.
                • 2. Batuwitage BT, Kingham JG, Morgan NE, Bartlett RL. Inappropriate prescribing of proton pump inhibitors in primary care. Postgrad Med J 2007; 83: 66-68.
                • 3. Vaezi, MF, Yang YX, Howden CW. Complications of proton pump inhibitor therapy. Gastroenterology 2017; 153: 35-48.
                • 4. Reimer C. Safety of long-term PPI therapy. Best Pract Res Clin Gastroenterol 2013; 27: 443-454.
                • 5. Lødrup AB, Reimer C, Bytzer P. Systematic review: symptoms of rebound acid hypersecretion following proton pump inhibitor treatment. Scand J Gastroenterol 2013; 48: 515-522.
                • 6. Haastrup P, Paulsen MS, Begtrup LM, et al. Strategies for discontinuation of proton pump inhibitors: a systematic review. Fam Pract 2014; 31: 625-630.
                • 7. Reimer C, Bytzer P. Discontinuation of long-term proton pump inhibitor therapy in primary care patients: a randomized placebo-controlled trial in patients with symptom relapse. Eur J Gastroenterol Hepatol 2010; 22: 1182-1188.
                • 8. Murie J, Allen J, Simmonds R, de Wet C. Glad you brought it up: a patient-centred programme to reduce proton-pump inhibitor prescribing in general medical practice. Qual Prim Care 2012; 20: 141-148.
                • 9. Björnsson E, Abrahamsson H, Simrén M, et al. Discontinuation of proton pump inhibitors in patients on long-term therapy: a double-blind, placebo-controlled trial. Aliment Pharmacol Ther 2006; 24: 945-954.
                • 10. Inadomi, JM, Jamal R, Murata GH, et al. Step-down management of gastroesophageal reflux disease. Gastroenterology 2001; 121: 1095-1100.
                • 11. National Prescribing Service. Reviewing PPIs for GORD. June 2018. https://cdn0.scrvt.com/08ab3606b0b7a8ea53fd0b40b1c44f86/c052d66150fd152a/df9dd3c72fab/Reviewing-PPIs-for-GORD-algorithm-June-2018.pdf (viewed July 2018).
                • 12. Bytzer P. Goals of therapy and guidelines for treatment success in symptomatic gastroesophageal reflux disease patients. Am J Gastroenterol 2003; 98(3 Suppl): S31-S39.

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                  Gluten in “gluten-free” manufactured foods in Australia: a cross-sectional study

                  Emma P Halmos, Dean Clarke, Catherine Pizzey and Jason A Tye-Din
                  Med J Aust 2018; 209 (10): . || doi: 10.5694/mja18.00457
                  Published online: 12 November 2018

                  Patients with coeliac disease must strictly adhere to a gluten-free diet. Two potential sources of inadvertent gluten exposure are meals provided when dining out and manufactured “gluten-free” foods. A recent study1 found that 9% of gluten-free food samples from Melbourne food businesses failed to meet the national standard of “no detectable gluten”2. As no data on gluten levels in manufactured “gluten-free” foods in Australia have been published, we measured the gluten content of a broad sample of these foods.

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                  • 1 Royal Melbourne Hospital, Melbourne, VIC
                  • 2 Monash University Central Clinical School, Melbourne, VIC
                  • 3 National Measurement Institute, Melbourne, VIC
                  • 4 Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC


                  Correspondence: tyedin@wehi.edu.au
                  Acknowledgements: 

                  Emma Halmos was funded by a research grant from Coeliac Australia. We thank the Nielsen Company for their data on the most commonly purchased foods; and Martina Koeberl, Jasmit Khangurha and Rasika Wijerathne (National Measurement Institute) for conducting the food analyses.

                  Competing interests:

                  Jason Tye-Din is a co-inventor on patents pertaining to applications of gluten peptides in therapeutics, diagnostics, and non-toxic gluten; he is a shareholder in Nexpep and a consultant to ImmusanT (USA).

                  • 1. Halmos EP, Di Bella CA, Webster R, et al. Gluten in “gluten-free” food from food outlets in Melbourne: a cross-sectional study. Med J Aust 2018; 209: 42-43. <MJA full text>
                  • 2. Food Standards Australia New Zealand. Standard 1.2.7. Nutrition, health and related claims. Nov 2017. https://www.legislation.gov.au/Details/F2017C01048 (viewed Apr 2018).
                  • 3. Forbes GM, Dods K. Gluten content of imported gluten-free foods: national and international implications. Med J Aust 2016; 205: 316. <MJA full text>
                  • 4. Catassi C, Fabiani E, Iacono G, et al. A prospective, double-blind, placebo-controlled trial to establish a safe gluten threshold for patients with celiac disease. Am J Clin Nutr 2007; 85: 160-166.
                  • 5. Zurzolo GA, Peters RL, Koplin JJ, et al. The practice and perception of precautionary allergen labelling by the Australasian food manufacturing industry. Clin Exp Allergy 2017; 47: 961-968.

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                    Preventing ovarian failure associated with chemotherapy

                    Wanyuan Cui, Catharyn Stern, Martha Hickey, Fiona Goldblatt, Antoinette Anazodo, William S Stevenson and Kelly-Anne Phillips
                    Med J Aust 2018; 209 (9): . || doi: 10.5694/mja18.00190
                    Published online: 5 November 2018

                    Summary

                     

                    • Alkylating chemotherapy is often used to treat pre-menopausal women for various malignancies and autoimmune diseases. Chemotherapy-associated ovarian failure is a potential consequence of this treatment which can cause infertility, and increases the risk of other long term adverse health sequelae.
                    • Randomised trials, predominantly of women undergoing alkylating chemotherapy for breast cancer, have shown evidence for the efficacy of gonadotropin-releasing hormone agonists (GnRHa) in preventing chemotherapy-associated ovarian failure.
                    • The European St Gallen and United States National Comprehensive Cancer Network guidelines recommend the use of concurrent GnRHa to reduce the risk of ovarian failure for pre-menopausal women undergoing chemotherapy for breast cancer.
                    • The GnRHa goserelin, a monthly 3.6 mg depot subcutaneous injection, has recently been listed on the Australian Pharmaceutical Benefits Scheme to reduce risk of ovarian failure for pre-menopausal women receiving alkylating therapies for malignancy or autoimmune disease.
                    • The first dose of goserelin should ideally be administered at least 1 week before commencement of alkylating treatment and continued 4-weekly during chemotherapy.
                    • Concurrent goserelin use should now be considered for all pre-menopausal women due to commence alkylating chemotherapy (except those with incurable cancer), regardless of their childbearing status, in an effort to preserve their ovarian function. For women who have not completed childbearing, consideration of other fertility preservation options, such as cryopreservation of embryos or oocytes, is also important.

                     


                    • 1 Peter MacCallum Cancer Centre, Melbourne, VIC
                    • 2 University of Melbourne, Melbourne, VIC
                    • 3 Royal Women's Hospital, Melbourne, VIC
                    • 4 Flinders Medical Centre and Flinders University, Adelaide, SA
                    • 5 Kids Cancer Centre, Sydney Children's Hospital, Randwick, Sydney, NSW
                    • 6 Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Sydney, NSW
                    • 7 Royal North Shore Hospital, Sydney, NSW
                    • 8 Northern Clinical School, University of Sydney, Sydney, NSW


                    Correspondence: kelly.phillips@petermac.org
                    Acknowledgements: 

                    Kelly-Anne Phillips is a National Breast Cancer Foundation Practitioner Fellow. Martha Hickey is a National Health and Medical Research Council Practitioner Fellow. Antoinette Anazodo’s research is supported by Kids Cancer Alliance, Cancer Institute NSW Translational Cancer Research Centre (15/TRC/1-04), and CanTeen funding from the federal Department of Health.

                    Competing interests:

                    No relevant disclosures.

                    • 1. Australian Government Cancer Australia. Lymphoma statistics. https://lymphoma.canceraustralia.gov.au/statistics (viewed Jan 2018).
                    • 2. Australian Government Cancer Australia. Breast cancer statistics. https://breast-cancer.canceraustralia.gov.au/statistics (viewed Apr 2018).
                    • 3. Colvin M. Alkylating agents. In: Kufe DW, Pollock RE, Weichselbaum RR, et al, editors. Holland-Frei Cancer Medicine. 6th ed. Hamilton, ON: BC Decker, 2003.
                    • 4. Sklar CA, Mertens AC, Mitby P, et al. Premature menopause in survivors of childhood cancer: a report from the childhood cancer survivor study. J Natl Cancer Inst 2006; 98: 890-896.
                    • 5. Logan S, Perz J, Ussher JM, et al. A systematic review of patient oncofertility support needs in reproductive cancer patients aged 14 to 45 years of age. Psychooncology 2017; 27: 401-409.
                    • 6. Howard-Anderson J, Ganz PA, Bower JE, Stanton AL. Quality of life, fertility concerns, and behavioural health outcomes in younger breast cancer survivors: a systematic review. J Natl Cancer Inst 2012; 104: 386-405.
                    • 7. Jackisch C, Harbeck N, Huober J, et al. 14th St Gallen International Breast Cancer Conference 2015: Evidence, Controversies, Consensus – Primary Therapy of Early Breast Cancer: opinions expressed by German experts. Breast Care 2015; 10: 211-219.
                    • 8. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology. Fort Washington, PA: NCCN, 2017. https://www.nccn.org/professionals/physician_gls/pdf/aya.pdf (viewed Oct 2017).
                    • 9. Australian Government Department of Health. The Pharmaceutical Benefits Scheme. Goserelin. www.pbs.gov.au/medicine/item/1454M www.pbs.gov.au/medicine/item/1454M (viewed Dec 2017).
                    • 10. Demeestere I, Brice P, Peccatori FA, et al. Gonadotropin-releasing hormone agonist for the prevention of chemotherapy-induced ovarian failure in patients with lymphoma: 1-year follow-up of a prospective randomized trial. J Clin Oncol 2013; 31: 903-909.
                    • 11. Mar Fan HG, Houede-Tchen N, Chemerynsky I, et al. Menopausal symptoms in women undergoing chemotherapy-induced and natural menopause: a prospective controlled study. Ann Oncol 2010; 21: 983-987.
                    • 12. Shapiro CL, Manola J, Leboff M. Ovarian failure after adjuvant chemotherapy is associated with rapid bone loss in women with early-stage breast cancer. J Clin Oncol 2001; 19: 3306-3311.
                    • 13. Ryan J, Scali J, Carriere I, et al. Impact of a premature menopause on cognitive function in later life. BJOG 2014; 121: 1729-1739.
                    • 14. Rocca WA, Grossardt BR, De Andrade M, et al. Survival patterns after oophorectomy in premenopausal women: a population based cohort study. Lancet Oncol 2006; 7: 821-828.
                    • 15. Roness H, Kalich-Philosoph L, Meirow D. Prevention of chemotherapy induced ovarian damage: possible roles for hormonal and non hormonal attenuating agents. Hum Reprod Update 2014; 20: 759-774.
                    • 16. Millar RP, Lu Z, Pawson AJ, et al. Gonadotropin-Releasing Hormone Receptors. Endocr Rev 2004; 25: 235-275.
                    • 17. West CP, Baird DT. Suppression of ovarian activity by zoladex depot (ICI 118630), a long acting luteinizing hormone releasing hormone agonist analogue. Clin Endocrinol 1987; 26: 213-220.
                    • 18. Kerr JB, Hutt KJ, Michalak EM, et al. DNA damage-induced primordial follicle oocyte apoptosis and loss of fertility require TAp63-mediated induction of Puma and Noxa. Mol Cell 2012; 48: 343-352.
                    • 19. Ataya K, Rao LV, Lawrence E, Kimmel R. Luteinizing hormone- releasing hormone agonist inhibits cyclophosphamide induced ovarian follicular depletion in Rhesus monkeys. Biol Reprod 1995; 52: 365-372.
                    • 20. Munhoz RR, Pereira AA, Sasse AD, et al. Gonadotropin-releasing hormone agonists for ovarian function preservation in premenopausal women undergoing chemotherapy for early stage breast cancer: a systematic review and meta-analysis. JAMA Oncol 2016; 2: 65-73.
                    • 21. Moore HC, Unger JM, Phillips K, et al. Goserelin for ovarian protection during breast-cancer adjuvant chemotherapy. N Engl J Med 2015; 372: 923-932.
                    • 22. Del Mastro L, Boni L, Michelotti A, et al. Effect of the gonadotropin-releasing hormone analogue triptorelin on the occurrence of chemotherapy-induced early menopause in premenopausal women with breast cancer: a randomized trial. JAMA 2011; 306: 269-276.
                    • 23. Lambertini M, Boni L, Michelotti A, et al. Ovarian suppression with triptorelin during adjuvant breast cancer chemotherapy and long-term ovarian function, pregnancies, and disease-free survival: a randomized clinical trial. JAMA 2015; 314: 2632-2640.
                    • 24. Leonard RC, Adamson DJ, Bertelli G, et al. GnRH agonist for protection against ovarian toxicity during chemotherapy for early breast cancer: the Anglo Celtic Group OPTION trial. Ann Oncol 2017; 28: 1811-1816.
                    • 25. Garrido-Oyarzun MF, Castelo-Branco C. Controversies over the use of GnRH agonists for reduction of chemotherapy-induced gonadotoxicity. Climacteric 2016; 19: 522-525.
                    • 26. Giuseppe L, Attilio G, Edoardo DN, Loredana G, Cristina L, Vincenzo L. Ovarian function after cancer treatment in young women affected by Hodgkin disease (HD). Hematology 2007; 12: 141-147.
                    • 27. Waxman JH, Ahmed R, Smith D, et al. Failure to preserve fertility in patients with Hodgkin’s disease. Cancer Chemother Pharmacol 1987; 19: 159-162.
                    • 28. Demeestere I, Brice P, Peccatori FA, et al. No evidence for the benefit of gonadotropin-releasing hormone agonist in preserving ovarian function and fertility in lymphoma survivors treated with chemotherapy: Final long-term report of a prospective randomized trial. J Clin Oncol 2016; 34: 2568-2574.
                    • 29. Lambertini M, Falcone T, Unger JM, et al. Correspondence: Debated role of ovarian protection with gonadotrophin-releasing hormone agonists during chemotherapy for preservation of ovarian function and fertility in women with cancer. J Clin Oncol 2017; 35: 804-805.
                    • 30. Zhang Y, Xiao Z, Wang Y, et al. Gonadotropin-releasing hormone for preservation of ovarian function during chemotherapy in lymphoma patients of reproductive age: a summary based on 434 patients. PLoS One 2013; 8: e80444.
                    • 31. Salooja N, Szydlo RM, Socie G, et al. Pregnancy outcomes after peripheral blood or bone marrow transplantation: a retrospective survey, Lancet 2001; 358: 271-276.
                    • 32. Anazodo AC, Stern C, McLachlan RI, et al. A study protocol for the Australasian oncofertility registry: monitoring referral patterns and the uptake, quality and complications of fertility preservation strategies in Australia and New Zealand. J Adolesc Young Adult Oncol 2016; 5: 215-225.
                    • 33. Boumpas DT, Austin H, Vaughan EM, et al. Risk for sustained amenorrhea in patients with systemic lupus erythematosus receiving intermittent pulse cyclophosphamide therapy. Ann Intern Med 1993; 119: 366-369.
                    • 34. Blumenfeld Z. Preservation of fertility and ovarian function and minimising gonadotoxicity in young women with systemic lupus erythematosus treated by chemotherapy. Lupus 2000; 9: 401-405.
                    • 35. Clowse M, Behera M, Anders CK, et al. Ovarian preservation by GnRH agonists during chemotherapy: a metaanalysis. J Womens Health 2009; 18: 311-319.
                    • 36. Somers EC, Marder W, Christman GM, et al. Use of a gonadotropin-releasing hormone analog for protection against premature ovarian failure during cyclophosphamide therapy in women with severe lupus. Arthritis Rheum 2005; 52: 2261-2767.
                    • 37. Goldhirsch A, Gelber RD, Castiglione M. The magnitude of endocrine effects of adjuvant chemotherapy for premenopausal breast cancer patients. Ann Oncol 1990; 1: 183-188.
                    • 38. Katsifis GE, Tzioufas AG. Ovarian failure in systemic lupus erythematosus patients treated with pulsed intravenous cyclophosphamide. Lupus 2004; 13: 673-678.
                    • 39. United States Food and Drug Administration. Zoladex (goserelin acetate implant) 3.6 mg. https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/019726s059,020578s037lbl.pdf (viewed Sept 2018).

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                      Updated clinical practice guidelines on pregnancy care

                      Caroline SE Homer, Jeremy Oats, Philippa Middleton, Jenny Ramson and Samantha Diplock
                      Med J Aust 2018; 209 (9): . || doi: 10.5694/mja18.00286
                      Published online: 5 November 2018

                      Abstract

                      Introduction: The clinical practice guidelines on pregnancy care have been developed to provide reliable and standardised guidance for health professionals providing antenatal care in Australia. They were originally released as the Clinical Practice Guidelines: Antenatal Care in two separate editions (modules 1 and 2) in 2012 and 2014. These modules have now been combined and updated to form a single set of consolidated guidelines that were publicly released in February 2018 as the Clinical Practice Guidelines: Pregnancy Care. Eleven topics have been updated and new guidance on substance use in pregnancy has been added.

                      Main recommendations: The updated guidelines include the following key changes to practice:

                      • recommend routine testing for hepatitis C at the first antenatal visit;
                      • recommend against routine testing for vitamin D status in the absence of a specific indication;
                      • recommend discussing weight change, diet and physical activity with all pregnant women; and
                      • recommend offering pregnant women the opportunity to be weighed at every antenatal visit and encouraging women to self-monitor weight gain.

                      Changes in management as a result of the guidelines: The guidelines will enable pregnant women diagnosed with hepatitis C to be identified and thus avoid invasive procedures that increase the risk of mother-to-baby transmission. Women can be treated postpartum, reducing the risk of liver disease and removing the risk of perinatal infection for subsequent pregnancies. Routine testing of all pregnant women for vitamin D status and subsequent vitamin D supplementation is not supported by evidence and should cease as the benefits and harms of vitamin D supplementation remain unclear. The recommendation for health professionals to provide advice to pregnant women about weight, diet and physical activity, and the opportunity to be weighed will help women to make changes leading to better health outcomes for themselves and their babies.


                      • 1 Centre for Midwifery, Child and Family Health, UTS Sydney, Sydney, NSW
                      • 2 Burnet Institute, Melbourne, VIC
                      • 3 Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC
                      • 4 Robinson Research Institute, University of Adelaide, Adelaide, SA
                      • 5 Ampersand Health Science Writing, Tanja, NSW
                      • 6 Department of Health, Canberra, ACT


                      Correspondence: caroline.homer@uts.edu.au
                      Acknowledgements: 

                      The review of the guidelines was jointly funded by the Australian Government and the states and territories. The review was project managed by the Australian Government Department of Health. The authors acknowledge the engagement and support of the Australian College of Midwives, the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives, the Royal Australian College of General Practitioners and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. EWG members who have supported the review of the guidelines: Professor Jeremy Oats, University of Melbourne (co-chair); Professor Caroline Homer, University of Technology Sydney and the Australian College of Midwives (co-chair); Associate Professor Philippa Middleton, South Australian Health and Medical Research Institute Adelaide; Dr Martin Byrne, Royal Australian College of General Practitioners; Ann Catchlove, consumer representative; Lisa Clements, migrant and refugee women representative; Dr Anthony Hobbs, Commonwealth Deputy Chief Medical Officer; Tracy Martin, WA Health; Professor Sue McDonald, La Trobe University; Dr Sarah Jane McEwan, Western Australian Country Hedland Service; Professor Michael Permezel, Royal Australian College of Obstetricians and Gynaecologists; Adjunct Professor Debra Thoms, Commonwealth Chief Nursing and Midwifery Officer; Louis Young, Department of Health (Secretariat); Samantha Diplock, Department of Health (Secretariat); Anita Soar, Department of Health (Secretariat); and Jenny Ramson, Ampersand Health Science Writing (technical writer).

                      Competing interests:

                      No relevant disclosures.

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