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    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

    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.

    • 1. Reinhart K, Daniels R, Kissoon N, et al. Recognizing sepsis as a global health priority — a WHO resolution. N Engl J Med 2017; 377: 414-417.
    • 2. World Health Organization. Service delivery and safety: improving the prevention, diagnosis and clinical management of sepsis. http://www.who.int/servicedeliverysafety/areas/sepsis/en/ (viewed June 2018).
    • 3. Fleischmann C, Scherag A, Adhikari NK, et al. Assessment of global incidence and mortality of hospital-treated sepsis: current estimates and limitations. Am J Respir Crit Care Med 2016; 193: 259-272.
    • 4. Finfer S, Machado FR. The global epidemiology of sepsis. Does it matter that we know so little? Am J Respir Crit Care Med 2016; 193: 228-230.
    • 5. Rudd KE, Delaney A, Finfer S. Counting sepsis, an imprecise but improving science. JAMA 2017; 318: 1228-1229.
    • 6. Singer M, Deutschman CS, Seymour C. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 2016; 315: 801-810.
    • 7. Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001; 29: 1303-1310.
    • 8. Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 2003; 348: 1546-1554.
    • 9. Rhee C, Dantes R, Epstein L, et al. Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009-2014. JAMA 2017; 318: 1241-1249.
    • 10. Finfer S, Bellomo R, Lipman J, et al. Adult-population incidence of severe sepsis in Australian and New Zealand intensive care units. Intensive Care Med 2004; 30: 589-596.
    • 11. Kaukonen KM, Bailey M, Suzuki S, et al. Mortality related to severe sepsis and septic shock among critically ill patients in Australia and New Zealand, 2000–2012. JAMA 2014; 311: 1308-1316.
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    • 13. Bernard GR, Vincent J-L, Laterre P-F, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 2001; 344: 699-709.
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    • 19. Danai PA, Sinha S, Moss M, et al. Seasonal variation in the epidemiology of sepsis. Crit Care Med 2007; 35: 410-415.

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

      Anne Duggan, Iain J Skinner and Alice L Bhasale
      Med J Aust 2018; 209 (10): . || doi: 10.5694/mja18.00556
      Published online: 10 September 2018

      Maintaining the quality of colonoscopies is vital if promised reductions in colorectal cancer are to be achieved

      In many ways, colonoscopy has been a transformative health technology. By allowing the early identification and removal of polyps, it reduces colorectal cancer incidence and mortality. Evidence for population screening using a faecal occult blood test and follow-up colonoscopy was based on randomised controlled studies that found a reduction in colorectal cancer mortality of 28–32% with flexible sigmoidoscopy.1 It is estimated that by 2040, the National Bowel Cancer Screening Program will prevent 92 200 cases of colorectal cancer and 59 000 deaths, using conservative modelling based on current participation of just 40%.2 These benefits are substantial, given that bowel cancer is the second highest cause of cancer death in Australia and participation in the National Bowel Cancer Screening Program is increasing.3 However, without high quality and appropriate use of colonoscopy, patients may be exposed to avoidable adverse outcomes without significant benefit. These include procedural and sedation-related complications, missed cancers, missed adenomas (hence increased risk of bowel cancer), and adverse patient experience. Further, overuse of the procedure in patients who are unlikely to benefit from it results in low value care and reduces access for patients in greater need. In order to ensure the maximum benefit to the Australian population, the Australian Commission on Safety and Quality in Health Care has developed a Colonoscopy Clinical Care Standard (www.safetyandquality.gov.au/our-work/clinical-care-standards/colonoscopy-clinical-care-standard).


      • 1 Australian Commission on Safety and Quality in Health Care, Sydney, NSW
      • 2 St Vincent's Private Hospital, Melbourne, VIC


      Acknowledgements: 

      We thank Brett Abbenbroek for his contribution to the development of the Clinical Care Standard, and the Colonoscopy Clinical Care Standard Topic Working Group for their expert advice. Funding for the development of the Colonoscopy Clinical Care Standard was provided by the Australian Government Department of Health.

      Competing interests:

      No relevant disclosures.

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        Improving drug allergy management in Australia: education, communication and accurate information

        Michaela Lucas, Richard KS Loh and William B Smith
        Med J Aust 2019; 210 (2): . || doi: 10.5694/mja18.00467
        Published online: 3 September 2018

        Drug allergy education and effective communication of accurate information can optimise drug allergy management and patient safety

        A drug allergy label is often applied to a patient after an adverse drug reaction (ADR), usually resulting in subsequent avoidance of the drug and related drugs. Recent attention has focused on antibiotic allergy labels and the benefits of delabelling.1 But drug allergy labels, which occur in up to 35% of patient electronic health records (EHRs), encompass all types of medications, with antibiotics, opiates and non-steroidal anti-inflammatory drugs being among the most common (Box 1).2 Accurate and effective communication of drug allergy is crucial for safe prescribing, including sufficient information to enable assessment of the risk of re-exposure compared with the risk of withholding the index drug and related drugs.


        • 1 Sir Charles Gairdner Hospital, Perth, WA
        • 2 Princess Margaret Hospital for Children, Perth, WA
        • 3 Royal Adelaide Hospital, Adelaide, SA
        • 4 AllergySA, Adelaide, SA


        Correspondence: William.Smith@sa.gov.au
        Acknowledgements: 

        We thank Sandra Vale, National Allergy Strategy coordinator, for her contribution to the drafting of this article. We also thank Connie Katelaris, James Yun, Maria Said, Andrew Lucas, Syed Ali and the members of the Australasian Society of Clinical Immunology and Allergy Drug Allergy Working Party for their contribution to this manuscript.

        Competing interests:

        No relevant disclosures.

        • 1. Trubiano JA, Grayson ML, Thursky KA, et al. How antibiotic allergy labels may be harming our most vulnerable patients. Med J Aust 2018; 208: 469–470. https://www.mja.com.au/journal/2018/208/11/how-antibiotic-allergy-labels-may-be-harming-our-most-vulnerable-patients
        • 2. Zhou L, Dhopeshwarkar N, Blumenthal KG, et al. Drug allergies documented in electronic health records of a large healthcare system. Allergy 2016; 71: 1305–1313.
        • 3. Chaudhry T, Hissaria P, Wiese M, et al. Oral drug challenges in non‐steroidal anti‐inflammatory drug‐induced urticaria, angioedema and anaphylaxis. Intern Med J 2012; 42: 665–667.
        • 4. Petitpain N, Argoullon L, Masmoudi K, et al. Neuromuscular blocking agents induced anaphylaxis: results and trends of a French pharmacovigilance survey from 2000 to 2012. Allergy 2018. https://doi.org/10.1111/all.13456. [Epub ahead of print]
        • 5. Kemp HI, Cook TM, Thomas M, Harper NJN. UK anaesthetists’ perspectives and experiences of severe perioperative anaphylaxis: NAP6 baseline survey. Br J Anaesth 2017; 119: 132–139.
        • 6. Florvaag E, Johansson SGO. The pholcodine case. Cough medicines, IgE‐sensitization, and anaphylaxis: a devious connection. World Allergy Organ J 2012; 5: 73–78.
        • 7. Katelaris CH, Smith WB. “Iodine allergy” label is misleading. Aust Prescr 2009; 32: 125–128.
        • 8. Mullins RJ, Wainstein BK, Barnes EH, et al. Increases in anaphylaxis fatalities in Australia from 1997 to 2013. Clin Exp Allergy 2016; 46: 1099–1110.
        • 9. Peter JG, Lehloenya R, Dlamini S, et al. Severe delayed cutaneous and systemic reactions to drugs: a global perspective on the science and art of current practice. J Allergy Clin Immunol Pract 2017; 5: 547–563.
        • 10. Shah NS, Ridgway JP, Pettit N, et al. Documenting penicillin allergy: the impact of inconsistency. PLoS One 2016; 11: e0150514.
        • 11. Morritt AN, Alexander DJ. Impact of junior doctor education on drug allergy documentation. Ann R Coll Surg Engl 2005; 87: 311–312.
        • 12. Trubiano JA, Worth LJ, Urbancic K, et al. Return to sender: the need to re‐address patient antibiotic allergy labels in Australia and New Zealand. Intern Med J 2016; 46: 1311–1317.
        • 13. Inglis JM, Caughey GE, Smith W, Shakib S. Documentation of penicillin adverse drug reactions in electronic health records: inconsistent use of allergy and intolerance labels. Intern Med J 2017; 47: 1292–1297.
        • 14. Blumenthal KG, Shenoy ES, Hurwitz S, et al. Effect of a drug allergy educational program and antibiotic prescribing guideline on inpatient clinical providers’ antibiotic prescribing knowledge. J Allergy Clin Immunol Pract 2014; 2: 407–413.
        • 15. Blumenthal KG, Shenoy ES, Varughese C, et al. Impact of a clinical guideline for prescribing antibiotics to inpatients with reported penicillin or cephalosporin allergies. Ann Allergy Asthma Immunol 2015; 115: 294–300.
        • 16. Trubiano JA, Pai Mangalore RP, Baey YW, et al. Old but not forgotten: Antibiotic allergies in General Medicine (the AGM Study). Med J Aust 2016; 204: 273. https://www.mja.com.au/journal/2016/204/7/old-not-forgotten-antibiotic-allergies-general-medicine-agm-study

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          Homeless health care: meeting the challenges of providing primary care

          Andrew Davies and Lisa J Wood
          Med J Aust 2018; 209 (5): . || doi: 10.5694/mja17.01264
          Published online: 3 September 2018

          Summary

           

          • People experiencing homelessness have multiple complex health conditions yet are typically disengaged from primary health care services and place a significant burden on the acute health system.
          • Barriers preventing people who are homeless from accessing primary care can be both personal and practical and include competing needs and priorities, illness and poor health, physical access to health services, difficulty in contacting services, medication security, and the affordability of health care. Differences in social status and perceptions of being judged can lead to relationship barriers to accessing primary care.
          • Key solutions include prioritising access to stable housing, continuity of health care, specialised homeless general practice, hospital inreach, discharge planning and coordinated care, general practice outreach, and medical recovery centres.

           


          • 1 Homeless Healthcare, Perth, WA
          • 2 University of Western Australia, Perth, WA


          Correspondence: andrew.davies@hhc.org.au
          Acknowledgements: 

          We thank Angela Gazey, Nuala Chapple and Jake Smith from the School of Population and Global Health, University of Western Australia, for their assistance in the preparation of this publication.

          Competing interests:

          No relevant disclosures.

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            The challenges in providing safe, effective, affordable cannabis-based medicines for unapproved indications

            Wayne D Hall and Michael Farrell
            Med J Aust 2018; 209 (5): . || doi: 10.5694/mja18.00445
            Published online: 3 September 2018

            A cautious response to public interest in medical uses of cannabis products remains appropriate

            Over the past 20 years or more, governments in many countries have struggled with how best to respond to the requests of patients, families and some doctors that they be allowed to use unapproved cannabis-based medicines to treat serious medical conditions that have failed to respond to conventional treatment.1 In Australia, parents of children with cancer or intractable forms of epilepsy have recently persuaded state and federal governments to permit access to cannabis-based products for medical use under the Special Access Scheme of the Therapeutic Goods Act.2


            • 1 Centre for Youth Substance Abuse Research, University of Queensland, Brisbane, QLD
            • 2 National Addiction Centre, King's College London, London, United Kingdom
            • 3 National Drug and Alcohol Research Centre, UNSW, Sydney, NSW


            Correspondence: w.hall@uq.edu.au
            Competing interests:

            We have each advised the Therapeutic Goods Administration on the evidence of the safety and effectiveness of cannabinoids in the treatment of various illnesses. Wayne Hall is a member of the Australian Advisory Council on the Medicinal Uses of Cannabis.

            • 1. Joy JE, Watson SJ, Benson JA, editors. Marijuana and medicine: assessing the science base. Washington (DC): The National Academies Press, 1999.
            • 2. Therapeutic Goods Administration. Guidance for the use of medicinal cannabis in Australia: overview. Version 1, December 2017. Canberra: Commonwealth of Australia, 2017. https://www.tga.gov.au/sites/default/files/guidance-use-medicinal-cannabis-australia-overview.pdf (viewed Jan 2018).
            • 3. Chen K-A, Farrar M, Cardamone M, et al. Cannabidiol for treating drug-resistant epilepsy in children: the New South Wales experience. Med J Aust 2018; 209: 217-221.
            • 4. Freeman JL. Safety of cannabidiol prescribed for children with refractory epilepsy. Med J Aust 2018; 209: 228-229.
            • 5. Stockings E, Zagic D, Campbell G, et al. Evidence for cannabis and cannabinoids for epilepsy: a systematic review of controlled and observational evidence. J Neurol Neurosurg Psychiatry 2018; 89: 741-753.
            • 6. US Food and Drug Administration. FDA approves first drug comprised of an active ingredient derived from marijuana to treat rare, severe forms of epilepsy [media release]. 25 June 2018. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm611046.htm (viewed June 2018).
            • 7. Lintzeris N, Driels J, Elias N, et al. Medicinal cannabis in Australia, 2016: the Cannabis as Medicine Survey (CAMS-16). Med J Aust 2018; 209: 211-216.
            • 8. Lucas P. It can’t hurt to ask; a patient-centered quality of service assessment of Health Canada’s medical cannabis policy and program. Harm Reduct J 2012; 9: 2.
            • 9. O’Connell TJ, Bou-Matar CB. Long term marijuana users seeking medical cannabis in California (2001–2007): demographics, social characteristics, patterns of cannabis and other drug use of 4117 applicants. Harm Reduct J 2007; 4: 16.
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            • 11. Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA 2015; 313: 2456-2473.
            • 12. Stockings E, Campbell G, Hall W, et al. Cannabis and cannabinoids for the treatment of people with chronic non-cancer pain conditions: a systematic review and meta-analysis of controlled and observational studies. Pain 2018; doi: 10.1097/j.pain.0000000000001293 [Epub ahead of print].

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              Medicare-funded cancer genetic tests: a note of caution

              Judy Kirk, Kristine K Barlow-Stewart, Nicola K Poplawski, Margaret Gleeson, Kathy Tucker and Michael Friedlander
              Med J Aust 2018; 209 (5): . || doi: 10.5694/mja17.01124
              Published online: 3 September 2018

              Clinicians need appropriate education and support in keeping pace with the genomics revolution

              Media headlines stating that genetic testing for patients with a high risk of breast and ovarian cancer are now free are somewhat misleading. Clinical genetic testing for heritable, germline mutations (pathogenic variants) in two major genes (BRCA1 and BRCA2) that are associated with a high risk of breast and ovarian cancer came into Australian practice in the mid-1990s, and were offered free of charge (but not under Medicare) to appropriate patients in public clinics. Until now, testing, which has proven clinical utility,1 has mostly been offered through a network of family cancer clinics and genetics services that provide expert genetic counselling and testing of these genes in the context of familial breast and ovarian cancer.


              • 1 Westmead Hospital, Sydney, NSW
              • 2 University of Sydney, Sydney, NSW
              • 3 Royal Adelaide Hospital, Adelaide, SA
              • 4 Hunter New England Local Health District, Newcastle, NSW
              • 5 Prince of Wales Hospital and Community Health Services, Sydney, NSW


              Correspondence: judy.kirk@sydney.edu.au
              Competing interests:

              All of the authors are involved in a research study about the mainstreaming of genetic testing for patients with ovarian cancer, which is funded by AstraZeneca. Michael Friedlander, Kathy Tucker and Margaret Gleeson have received honoraria for educational talks for AstraZeneca; Michael Friedlander has also participated in an advisory capacity.

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                Predictors of inpatient rehabilitation after total knee replacement: an analysis of private hospital claims data

                Chris Schilling, Catherine Keating, Anna Barker, Stephen F Wilson and Dennis Petrie
                Med J Aust 2018; 209 (5): . || doi: 10.5694/mja17.01231
                Published online: 27 August 2018

                Abstract

                Objective: To investigate inpatient rehabilitation rates after private total knee replacements (TKRs) in Australia since 2009; to quantify the contributions of hospital-, surgeon- and patient-related factors to predicting inpatient rehabilitation.

                Design: Retrospective cohort study; multivariate linear regression analysis of linked, de-identified Medibank administrative claims data and hospital casemix protocol data, adjusted for patient-related characteristics.

                Setting, participants: 35 389 patients undergoing Medibank-funded TKRs in 170 private hospitals in Australia, 2009–2016.

                Main outcome measures: Hospital inpatient rehabilitation rate; relative contributions of patient- and provider-related characteristics to variation in inpatient rehabilitation rates.

                Results: The overall inpatient rehabilitation rate increased from 31% in 2009 to 45% in 2016, but varied between hospitals (range, 0–100%). The reduction in mean acute length of stay during this period explained about 15% of this increase, and about 30% was explained by patient-related factors; more than half of the increase was explained by neither reduced length of stay or patient-related factors. Patient-related characteristics explained little of the variation in rates between hospitals. Rates at 27% of hospitals lay above the 95% confidence limit for the mean inpatient rehabilitation rate in private hospitals (38%), both before and after adjusting for patient-related factors. Provider characteristics explained three times as much of the variation as patient characteristics (75% v 25%); hospital-related factors made the largest contribution to variation (47%).

                Conclusion: Inpatient rehabilitation after TKR has increased in private health care during the past 8 years. Substantial variation in inpatient rehabilitation rates is not explained by patient-related factors, suggesting that some inpatient rehabilitation is low value care.

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                • 1 KPMG Australia, Melbourne, VIC
                • 2 Medibank Private, Melbourne, VIC
                • 3 University of Sydney, Sydney, NSW
                • 4 Centre for Health Economics, Monash University, Melbourne, VIC


                Correspondence: cschilling1@kpmg.com.au
                Acknowledgements: 

                Dennis Petrie is supported by Monash University and an Australian Research Council Discovery Early Career Researcher Award.

                Competing interests:

                Catherine Keating and Anna Barker are employed by Medibank Private. Anna Barker receives salary support from Monash University. Chris Schilling is employed by KPMG and received consultancy fees from Medibank Private to undertake the analysis presented in this article. Stephen Wilson has previously received consultancy fees from Medibank Private in relation to development of rehabilitation in the home.

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                  Dr Google in the ED: searching for online health information by adult emergency department patients

                  Anthony M Cocco, Rachel Zordan, David McD Taylor, Tracey J Weiland, Stuart J Dilley, Joyce Kant, Mahesha Dombagolla, Andreas Hendarto, Fiona Lai and Jennie Hutton
                  Med J Aust 2018; 209 (8): . || doi: 10.5694/mja17.00889
                  Published online: 20 August 2018

                  Abstract

                  Objective: To determine the prevalence, predictors, and characteristics of health-related internet searches by adult emergency department (ED) patients; to examine the effect of searching on the doctor–patient relationship and treatment compliance.

                  Design: A multi-centre, observational, cross-sectional study; a purpose-designed 51-item survey, including tools for assessing e-health literacy (eHEALS) and the effects of internet searching on the doctor–patient relationship (ISMII).

                  Setting, participants: 400 adult patients presenting to two large tertiary referral centre emergency departments in Melbourne, February–May 2017.

                  Outcome measures: Descriptive statistics for searching prevalence and characteristics, doctor–patient interaction, and treatment compliance; predictors of searching; effect of searching on doctor–patient interaction.

                  Results: 400 of 1056 patients screened for eligibility were enrolled; their mean age was 47.1 years (SD, 21.1 years); 51.8% were men. 196 (49.0%) regularly searched the internet for health information; 139 (34.8%) had searched regarding their current problem before presenting to the ED. The mean ISMII score was 30.3 (95% CI, 29.6–31.0); searching improved the doctor–patient interaction for 150 respondents (77.3%). Younger age (per 10-year higher age band: odds ratio [OR], 0.74; 95% CI, 0.61–0.91) and greater e-health literacy (per one-point eHEALS increase: OR, 1.11; 95% CI, 1.06–1.17) predicted searching the current problem prior to presentation; e-health literacy predicted ISMII score (estimate, 0.39; 95% CI, 0.20–0.39). Most patients would never or rarely doubt their diagnosis (79%) or change their treatment plan (91%) because of conflicting online information.

                  Conclusion: Online health care information was frequently sought before presenting to an ED, especially by younger and e-health literate patients. Searching had a positive impact on the doctor–patient interaction and was unlikely to reduce adherence to treatment.

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                  • 1 St Vincent's Hospital Melbourne, Melbourne, VIC
                  • 2 University of Melbourne, Melbourne, VIC
                  • 3 Austin Health, Melbourne, VIC
                  • 4 Eastern Health, Melbourne, VIC
                  • 5 Goulburn Valley Health, Shepparton, VIC
                  • 6 Bairnsdale Regional Health Service, Bairnsdale, VIC
                  • 7 Emergency Practice Innovation Centre, St Vincent's Hospital Melbourne, Melbourne, VIC


                  Acknowledgements: 

                  We thank Andrew Walby, director of Emergency Medicine, St. Vincent’s Hospital Melbourne, and Thomas Chan, director of Emergency Medicine, Austin Health, for supporting this investigation in their emergency departments in 2017.

                  Competing interests:

                  No relevant disclosures.

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                    Management of bronchiectasis in adults

                    Simone K Visser, Peter Bye and Lucy Morgan
                    Med J Aust 2018; 209 (4): . || doi: 10.5694/mja17.01195
                    Published online: 20 August 2018

                    Summary

                     

                    • Once neglected in research and underappreciated in practice, there is renewed interest in bronchiectasis unrelated to cystic fibrosis.
                    • Bronchiectasis is a chronic lung disease characterised by chronic cough, sputum production and recurrent pulmonary exacerbations. It is diagnosed radiologically on high resolution computed tomography chest scan by bronchial dilatation (wider than the accompanying artery).
                    • The causes of bronchiectasis are diverse and include previous respiratory tract infections, chronic obstructive pulmonary disease, asthma, immunodeficiency and connective tissue diseases. A large proportion of cases are idiopathic, reflecting our incomplete understanding of disease pathogenesis.
                    • Progress in the evidence base is reflected in the 2017 European management guidelines and the 2015 update to the Australian guidelines.
                    • Effective airway clearance remains the cornerstone of bronchiectasis management. This should be personalised and reviewed regularly by a respiratory physiotherapist.
                    • There is now robust evidence for the long term use of oral macrolide antibiotics in selected patients to reduce exacerbation frequency.
                    • The routine use of long term inhaled corticosteroids and/or long-acting bronchodilators should be avoided, unless concomitant chronic obstructive pulmonary disease or asthma exists.
                    • The evidence for nebulised agents including hypertonic saline, mannitol and antibiotics is evolving; however, access is challenging outside tertiary clinics, and nebulising equipment is required.
                    • Smokers should be supported to quit. All patients should receive influenza and pneumococcal vaccination. Patients with impaired exercise capacity should attend pulmonary rehabilitation.
                    • There is an important minority of patients for whom aetiology-specific treatment exists.
                    • The prevalence of bronchiectasis is increasing worldwide; however, the burden of disease within Australia is not well defined. To this end, the Australian Bronchiectasis Registry began recruitment in 2016 and is interoperable with the European and United States bronchiectasis registries to enable collaborative research.
                    • The recent addition of a bronchiectasis diagnosis-related group to the Australian Refined Diagnostic Related Group classification system will allow definition of the disease burden within the Australian hospital system.

                     


                    • 1 Royal Prince Alfred Hospital, Sydney, NSW
                    • 2 Concord Repatriation General Hospital, Sydney, NSW
                    • 3 Sydney Medical School, University of Sydney, Sydney, NSW


                    Correspondence: simonekvisser@gmail.com
                    Competing interests:

                    Lucy Morgan is Head of the Australian Bronchiectasis Registry Steering Committee.

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                      Improved relative survival of patients with B-cell non-Hodgkin lymphoma in Queensland, 1993–2012

                      Ian N Olver
                      Med J Aust 2018; 209 (4): . || doi: 10.5694/mja18.00626
                      Published online: 20 August 2018

                      Monoclonal antibody-based therapies are improving outcomes for patients with a range of cancers

                      Anti-cancer immunotherapy, including monoclonal antibodies to specific cell surface protein antigens, is proving to be a successful strategy in the emerging era of personalised medicine. This issue of the Journal includes the report of a retrospective study of the impact of one of the first therapeutic monoclonal antibodies, rituximab, on the relative survival of patients with non-Hodgkin lymphoma in Queensland between 1993 and 2012.1 Rituximab binds the CD20 antigen that is found on 90% of B cells, making it easier for other immune system cells to eliminate the cancerous cells (antibody-dependent cell-mediated immunity).


                      • Cancer Research Institute, University of South Australia, Adelaide, SA


                      Correspondence: ian.olver@unisa.edu.au
                      Competing interests:

                      No relevant disclosures.

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                      • 2. Mannetje A, De Roos AJ, Boffetta P, et al Occupation and risk of non-Hodgkin lymphoma and its subtypes: a pooled analysis from the InterLymph consortium. Environ Health Perspect 2016; 124: 396-405.
                      • 3. Perez EA, Romond EH, Suman VJ, et al. Trastuzumab plus adjuvant chemotherapy for human epidermal growth factor receptor 2-positive breast cancer: planned joint analysis of overall survival form NSABP B-31 and NCCTG N9831. J Clin Oncol 2014; 32: 3744-3752.
                      • 4. Zugmaier G, Gökbuget N, Klinger M, et al. Long-term survival and T-cell kinetics in relapsed/refractory ALL patients who achieved MRD response after blinatumomab treatment. Blood 2015; 126: 2578-2584.
                      • 5. Shen K, Ma X, Zhu C, et al. Safety and efficacy of trastuzumab emtansine in advanced human epidermal growth factor receptor 2-postive breast cancer: a meta-analysis. Sci Rep 2016; 6: 23262.
                      • 6. Auger-Quittet S, Duny Y, Daures J-P, Quittet P. Outcomes after 90yttrium-ibritumomab tiuxetan-BEAM in diffuse large B-cell lymphoma: a meta-analysis. Cancer Med 2014; 3: 927-938.
                      • 7. Botrel TE, Clark L, Paladini L, Clark O. Efficacy and safety of bevacizumab plus chemotherapy compared to chemotherapy alone in previously untreated advanced or metastatic colorectal cancer. BMC Cancer 2016; 16: 667.
                      • 8. Greiller L, Tomasini P, Barlesi F. Bevacizumab in the treatment of nonsquamous non-small cell lung cancer: clinical trial evidence and experience. Ther Adv Respir Dis 2016; 10: 485-491.
                      • 9. Letendre P, Monga V, Mihem M, Zakharia Y. Ipilimumab: from preclinical development to future clinical perspectives in melanoma. Future Oncol 2017; 13: 625-636.
                      • 10. Medina PJ, Adams VR. PD-1 pathway inhibitors: immune-oncology agents for restoring antitumour immune responses. Pharmacotherapy 2016; 36: 317-334.
                      • 11. Ning YM, Suzman D, Maher VE, et al. FDA approval summary: atezolizumab for the treatment of patients with progressive advanced urothelial carcinoma after platinum-containing chemotherapy. Oncologist 2017; 22: 743-749.

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