Topics

We need to train our rural medical workforce in deeper mental health care skills

The “droughts and flooding rains” of our “sunburnt country” have been part of the national consciousness for generations of Australians. So it is understandable that many of us may not recognise the impact of increasing drought and climate change in rural Australia. However, rural and remote Australians depend on the land, not only for their own livelihood, but also for the sustainability of their communities. We also know that rural and remote Australians have higher rates of mental health disorders and risk of suicide,1 but much less access to mental health services.2 In this issue of the MJA, Austin and colleagues3 report that drought compounds this disadvantage, placing farmers and their communities at greater risk of mental illness and disability.

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1 Rural Doctors Association Tasmania, St Helens, TAS
2 Australian National University, Canberra, ACT
3 Canberra Hospital, Canberra, ACT

Correspondence: louise.stone@anu.edu.au

Competing interests:

No relevant disclosures.

1. Australian Institute of Health and Welfare. A snapshot of men’s health in rural and remote Australia (AIHW Cat. No. PHE 120). Canberra: AIHW, 2010.
2. Meadows GN, Enticott JC, Inder B, et al. Better access to mental health care and the failure of the Medicare principle of universality. Med J Aust 2015; 202: 190-194. <MJA full text>
3. Austin EK, Handley T, Kiem AS, et al. Drought-related stress among farmers: findings from the Australian Rural Mental Health Study. Med J Aust 2018; 209: 159-165.
4. Watterson I, Rafter T, Wilson L, et al. Projections: atmosphere and the land. In: Penny Whetton, editor. Climate change in Australia: projections for Australia’s Natural Resource Management regions. Canberra: Commonwealth Scientific and Industrial Research Organisation, Bureau of Meteorology, 2015; pp. 90-141. https://www.climatechangeinaustralia.gov.au/media/ccia/2.1.6/cms_page_media/168/CCIA_2015_NRM_TR_Chapter%207.pdf (viewed June 2018).
5. Fritze JG, Blashki GA, Burke S, Wiseman J. Hope, despair and transformation: climate change and the promotion of mental health and wellbeing. Int J Ment Health Syst 2008; 2: 13.
6. Patel V, Saxena S, Frankish H, Boyce N. Sustainable development and global mental health — a Lancet Commission. Lancet 2016; 387: 1143-1145.
7. Kleinman A. Global mental health: a failure of humanity. Lancet 2009; 374: 603-604.
8. Bishop L, Ransom A, Laverty M, Gale L. Mental health in remote and rural communities. Canberra: Royal Flying Doctor Service of Australia, 2017. https://www.flyingdoctor.org.au/assets/documents/RN031_Mental_Health_D5.pdf (viewed June 2018).
9. Australian Institute of Health and Welfare. Mental health services in Australia. Updated May 2018. https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/summary/prevalence-and-policies (viewed June 2018).
10. Steel Z, McDonald R, Silove D, et al. Pathways to the first contact with specialist mental health care. Aust N Z J Psychiatry 2006; 40: 347-354.
11. Hickie IB, Davenport TA, Pirkis JE, et al. General practitioners’ response to depression and anxiety in the Australian community: a preliminary analysis. Med J Aust 2004; 181 (7 Suppl): S15-S20. <MJA full text>
12. Kelly BJ, Stain HJ, Coleman C, et al. Mental health and well-being within rural communities: the Australian Rural Mental Health Study. Aust J Rural Health 2010; 18: 16-24.
13. Potiriadis M, Chondros P, Gilchrist G, et al. How do Australian patients rate their general practitioner? A descriptive study using the General Practice Assessment Questionnaire. Med J Aust 2008; 189: 215-219. <MJA full text>
14. Wakerman J, Humphreys J, Lyle D, et al. Overcoming access and equity problems relating to primary health care services in rural and remote Australia. Bendigo: Centre of Research Excellence in Rural and Remote Primary Health Care, 2015. https://openresearch-repository.anu.edu.au/bitstream/1885/139217/3/Wakerman%20Full%20report.pdf (viewed June 2018).
15. Scott A. Getting the balance right between generalism and specialisation: does remuneration matter? Aust Fam Physician 2014; 43: 229-232.

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Perspectives

A shift in scholarly publishing practices and the growing menace of predatory journals

Peter L Munk, Tyler M Coupal and Wilfred CG Peh

Med J Aust 2018; 209 (4): . || doi: 10.5694/mja17.00892
Published online: 20 August 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Information science

A certification process by an independent agency would help tackle the threat of predatory journals

The past two decades have seen many changes in scholarly publishing — something that has largely been the result of the advent of the internet and its growing influence on our lives. In an effort to adapt to this new age of technology, many journals have developed online editions and some journals have even switched over entirely to online editions. A step beyond this has been the implementation of open access journal publication, which continues to become more commonplace within current publishing practices.

1 Vancouver General Hospital, Vancouver, BC, Canada
2 Canadian Association of Radiologists Journal, Vancouver, BC, Canada
3 Khoo Teck Puat Hospital, Singapore

Correspondence: Peter.Munk@vch.ca

Competing interests:

No relevant disclosures.

1. Haug C. The downside of open-access publishing. N Engl J Med 2013; 368; 791-793.
2. Butler D. Investigating journals: the dark side of publishing. Nature 2013; 495: 433-435.
3. Shamseer L, Moher D, Maduekwe O, et al. Potential predatory and legitimate biomedical journals: can you tell the difference? A cross-sectional comparison. BMC Med 2017; 15: 28.
4. Bowman JD. Predatory publishing, questionable peer review, and fraudulent conferences. Am J Pharm Educ 2014; 78; 176.
5. Shen C, Björk BC. “Predatory” open access: a longitudinal study of article volumes and market characteristics. BMC Med 2015; 13: 230.
6. Clark J, Smith R. Firm action needed on predatory journals. BMJ 2015; 350: h210.
7. Manca A, Cugusi L, Dvir Z, Deriu F. PubMed should raise the bar for journal inclusion. Lancet 2017; 390: 734-735.
8. Manca A, Martinez G, Cugusi L, et al. The surge of predatory open-access in neurosciences and neurology. Neuroscience 2017; 353: 166-173.
9. Beall, J. Best practices for scholarly authors in the age of predatory journals. Ann R Coll Surg Engl 2016; 98: 77-79.
10. Anderson R. Cabell’s new predatory journal blacklist: a review. The Scholarly Kitchen 2017; 25 July. https://scholarlykitchen.sspnet.org/2017/07/25/cabells-new-predatory-journal-blacklist-review (viewed Aug 2017).
11. Bohannon J. Who’s afraid of peer review? Science 2013; 342: 60-65.

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Perspectives

Screening for spinal muscular atrophy

Hugo Sampaio, Bridget Wilcken and Michelle Farrar

Med J Aust 2018; 209 (4): . || doi: 10.5694/mja17.00772
Published online: 20 August 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Nervous system diseases

Environment and public health

Pediatric medicine

Early diagnosis allows the possibility of starting treatment at a young age to achieve better outcomes

Rapid advances in technology and novel disease-modifying treatments will increase demands for early diagnosis and screening for many severe childhood conditions. This is exemplified by spinal muscular atrophy (SMA).

1 Sydney Children's Hospital, Sydney, NSW
2 Children's Hospital at Westmead, Sydney, NSW
3 UNSW Sydney, Sydney, NSW

Correspondence: michelle.farrar@health.nsw.gov.au

Acknowledgements:

Michelle Farrar received support from the Motor Neurone Diseases Research Institute of Australia Beryl Bayley MND Postdoctoral Fellowship.

Competing interests:

Michelle Farrar has received honoraria from Biogen for consultancy.

1. Farrar MA, Vucic S, Johnston HM, et al. Pathophysiological insights derived by natural history and motor function of spinal muscular atrophy. J Pediatr 2013; 162: 155-159.
2. Feldkötter M, Schwarzer V, Wirth R, et al. Quantitative analyses of SMN1 and SMN2 based on real-time lightCycler PCR: fast and highly reliable carrier testing and prediction of severity of spinal muscular atrophy. Am J Hum Genet 2002; 70: 358-368.
3. Lefebvre S, Bürglen L, Reboullet S, et al. Identification and characterization of a spinal muscular atrophy-determining gene. Cell 1995; 80: 155-165.
4. Monani UR, Lorson CL, Parsons DW, et al. A single nucleotide difference that alters splicing patterns distinguishes the SMA gene SMN1 from the copy gene SMN2. Hum Mol Genet 1999; 8: 1177-1183.
5. Sugarman EA, Nagan N, Zhu H, et al. Pan-ethnic carrier screening and prenatal diagnosis for spinal muscular atrophy: clinical laboratory analysis of > 72,400 specimens. Eur J Hum Genet 2012; 20: 27-32.
6. Farrar MA, Teoh HL, Carey KA, et al. Nusinersen for SMA: expanded access programme. J Neurol Neurosurg Psychiatry 2018. doi: 10.1136/jnnp-2017-317412 [Epub ahead of print].
7. Farrar MA, Park SB, Vucic S, et al. Emerging therapies and challenges in spinal muscular atrophy. Ann Neurol 2017; 81: 355-368.
8. Finkel RS, Mercuri E, Darras BT, et al. Nusinersen versus sham control in infantile-onset spinal muscular atrophy. N Engl J Med 2017; 377: 1723-1732.
9. Bertini E, Hwu WL, Reyna SP, et al. Efficacy and safety of nusinersen in infants with presymptomatic spinal muscular atrophy (SMA): interim results from the NURTURE study. Eur J Paediatr Neurol 2017; 21: e14.
10. Wilson JM, Jungner G. Principles and practice of screening for disease. Public health papers no. 34. Geneva: World Health Organization; 1968. http://apps.who.int/iris/bitstream/10665/37650/17/WHO_PHP_34.pdf (viewed June 2018).
11. Swoboda KJ, Prior TW, Scott CB, et al. Natural history of denervation in SMA: relation to age, SMN2 copy number, and function. Ann Neurol 2005; 57: 704-712.
12. Rothwell E, Anderson RA, Swoboda KJ, et al. Public attitudes regarding a pilot study of newborn screening for spinal muscular atrophy. Am J Med Genet A 2013; 161a: 679-686.
13. Taylor JL, Lee FK, Yazdanpanah GK, et al. Newborn blood spot screening test using multiplexed real-time PCR to simultaneously screen for spinal muscular atrophy and severe combined immunodeficiency. Clin Chem 2015; 61: 412-419.
14. Phan HC, Taylor JL, Hannon H, Howell R. Newborn screening for spinal muscular atrophy: anticipating an imminent need. Semin Perinatol 2015; 39: 217-229.
15. Verhaart IE, Robertson A, Wilson IJ, et al. Prevalence, incidence and carrier frequency of 5q-linked spinal muscular atrophy — a literature review. Orphanet J Rare Dis 2017; 12: 124.
16. Boardman FK, Young PJ, Griffiths FE. Population screening for spinal muscular atrophy: a mixed methods study of the views of affected families. Am J Med Genet A 2017; 173: 421-434.
17. Rowe H, Holton S, Kirkman M, et al. Prevalence and distribution of unintended pregnancy: the Understanding Fertility Management in Australia National Survey. Aust N Z J Public Health 2016; 40: 104-109.

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Narrative review

Transcatheter aortic valve implantation: a new standard of care

Adam J Nelson, Nicholas J Montarello, Claudia S Cosgrove, Ross L Roberts-Thomson, Sinny Delacroix, Ramesh G Chokka, Joseph K Montarello and Stephen G Worthley

Med J Aust 2018; 209 (3): . || doi: 10.5694/mja17.01255
Published online: 6 August 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Anatomy and physiology

Cardiovascular diseases

Summary

Aortic stenosis is the most common valvular lesion requiring intervention and with an ageing population, its burden is likely to increase.
Increasing comorbidity and a desire for less invasive treatment strategies has facilitated the expansion of percutaneous aortic valve therapies.
Robust clinical trial data are now available to support the role of transcatheter aortic valve implantation (TAVI) in patients of prohibitive, high and now intermediate surgical risk.
The introduction of a Medicare Benefits Schedule reimbursement is likely to see TAVI use grow exponentially in Australia over the next 5 years.
Clinical trials evaluating low risk patients may be the final frontier to see TAVI become the standard of care for most patients with severe aortic stenosis.

Royal Adelaide Hospital, Adelaide, SA

Correspondence: adam.nelson@adelaide.edu.au

Competing interests:

Stephen Worthley consults for and has received honoraria from Medtronic and Abbott.

1. Yeh RW, Sidney S, Chandra M, et al. Population trends in the incidence and outcomes of acute myocardial infarction. N Engl J Med 2010; 362: 2155-2165.
2. Nkomo VT, Gardin JM, Skelton TN, et al. Burden of valvular heart diseases: a population-based study. Lancet 2006; 368: 1005-1011.
3. Ross J, Jr., Braunwald E. Aortic stenosis. Circulation 1968; 38: 61-67.
4. Ben-Dor I, Pichard AD, Gonzalez MA, et al. Correlates and causes of death in patients with severe symptomatic aortic stenosis who are not eligible to participate in a clinical trial of transcatheter aortic valve implantation. Circulation 2010; 122: S37-S42.
5. Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2010; 363: 1597-1607.
6. Harken DE, Soroff HS, Taylor WJ, et al. Partial and complete prostheses in aortic insufficiency. J Thorac Cardiovasc Surg 1960; 40: 744-762.
7. Iung B, Cachier A, Baron G, et al. Decision-making in elderly patients with severe aortic stenosis: why are so many denied surgery? Eur Heart J 2005; 26: 2714-2720.
8. Layland JJ, Bell B, Mullany D, Walters DL. Percutaneous management of aortic stenosis in high-risk patients. Med J Aust 2010; 192: 520-525. <MJA full text>
9. Cribier A, Eltchaninoff H, Bash A, et al. Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description. Circulation 2002; 106: 3006-3008.
10. Anderson RP. First publications from the Society of Thoracic Surgeons National Database. Ann Thorac Surg 1994; 57: 6-7.
11. O’Brien SM, Shahian DM, Filardo G, et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 2-isolated valve surgery. Ann Thorac Surg 2009; 88: S23-S42.
12. Kapadia SR, Leon MB, Makkar RR, et al. 5-year outcomes of transcatheter aortic valve replacement compared with standard treatment for patients with inoperable aortic stenosis (PARTNER 1): a randomised controlled trial. Lancet 2015; 385: 2485-2491.
13. Popma JJ, Adams DH, Reardon MJ, et al. Transcatheter aortic valve replacement using a self-expanding bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery. J Am Coll Cardiol 2014; 63: 1972-1981.
14. Kodali S, Thourani VH, White J, et al. Early clinical and echocardiographic outcomes after SAPIEN 3 transcatheter aortic valve replacement in inoperable, high-risk and intermediate-risk patients with aortic stenosis. Eur Heart J 2016; 37: 2252-2262.
15. Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 2011; 364: 2187-2198.
16. Mack MJ, Leon MB, Smith CR, et al. 5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial. Lancet 2015; 385: 2477-2484.
17. Adams DH, Popma JJ, Reardon MJ. Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J Med 2014; 371: 967-968.
18. Reardon MJ, Adams DH, Kleiman NS, et al. 2-year outcomes in patients undergoing surgical or self-expanding transcatheter aortic valve replacement. J Am Coll Cardiol 2015; 66: 113-121.
19. Leon MB, Smith CR, Mack MJ, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med 2016; 374: 1609-1620.
20. Reardon MJ, Van Mieghem NM, Popma JJ, et al. Surgical or transcatheter aortic-valve replacement in intermediate-risk patients. N Engl J Med 2017; 376: 1321-1331.
21. Sondergaard L, Steinbruchel DA, Ihlemann N, et al. Two-year outcomes in patients with severe aortic valve stenosis randomized to transcatheter versus surgical aortic valve replacement: the All-Comers Nordic Aortic Valve Intervention Randomized Clinical Trial. Circ Cardiovasc Interv 2016; 9: e003665.
22. Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 2009; 360: 961-972.
23. Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2017; 135: e1159-e1195.
24. Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J 2017; 38: 2739-2791.
25. Lanken PN, Ahlheit BD, Crawford S, et al. Withholding and withdrawing life-sustaining therapy. Am Rev Respir Dis 1991; 144: 726-731.
26. Schoenenberger AW, Stortecky S, Neumann S, et al. Predictors of functional decline in elderly patients undergoing transcatheter aortic valve implantation (TAVI). Eur Heart J 2013; 34: 684-692.
27. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56: M146-M156.
28. Rodes-Cabau J, Mok M. Working toward a frailty index in transcatheter aortic valve replacement: a major move away from the “eyeball test”. JACC Cardiovasc Interv 2012; 5: 982-983.
29. Kahlert P, Knipp SC, Schlamann M, et al. Silent and apparent cerebral ischemia after percutaneous transfemoral aortic valve implantation: a diffusion-weighted magnetic resonance imaging study. Circulation 2010; 121: 870-878.
30. Nombela-Franco L, Webb JG, de Jaegere PP, et al. Timing, predictive factors, and prognostic value of cerebrovascular events in a large cohort of patients undergoing transcatheter aortic valve implantation. Circulation 2012; 126: 3041-3053.
31. Webb J, Rodes-Cabau J, Fremes S, et al. Transcatheter aortic valve implantation: a Canadian Cardiovascular Society position statement. Can J Cardiol 2012; 28: 520-528.
32. Kahlert P, Al-Rashid F, Dottger P, et al. Cerebral embolization during transcatheter aortic valve implantation: a transcranial Doppler study. Circulation 2012; 126: 1245-1255.
33. Schmidt T, Akdag O, Wohlmuth P, et al. Histological findings and predictors of cerebral debris from transcatheter aortic valve replacement: the ALSTER experience. J Am Heart Assoc 2016; 5: e004399.
34. Bagur R, Solo K, Alghofaili S, et al. Cerebral embolic protection devices during transcatheter aortic valve implantation: systematic review and meta-analysis. Stroke 2017; 48: 1306-1315.
35. Haussig S, Mangner N, Dwyer MG, et al. Effect of a cerebral protection device on brain lesions following transcatheter aortic valve implantation in patients with severe aortic stenosis: the CLEAN-TAVI Randomized Clinical Trial. JAMA 2016; 316: 592-601.
36. Gerckens U, Tamburino C, Bleiziffer S, et al. Final 5-year clinical and echocardiographic results for treatment of severe aortic stenosis with a self-expanding bioprosthesis from the ADVANCE Study. Eur Heart J 2017; 38: 2729-2738.
37. Foroutan F, Guyatt GH, Otto CM, et al. Structural valve deterioration after transcatheter aortic valve implantation. Heart 2017; 103: 1899-1905.
38. Beohar N, Kirtane AJ, Blackstone E, et al. Trends in complications and outcomes of patients undergoing transfemoral transcatheter aortic valve replacement: experience from the PARTNER continued access registry. JACC Cardiovasc Interv 2016; 9: 355-363.
39. Kodali S, Pibarot P, Douglas PS, et al. Paravalvular regurgitation after transcatheter aortic valve replacement with the Edwards sapien valve in the PARTNER trial: characterizing patients and impact on outcomes. Eur Heart J 2015; 36: 449-456.
40. Athappan G, Patvardhan E, Tuzcu EM, et al. Incidence, predictors, and outcomes of aortic regurgitation after transcatheter aortic valve replacement: meta-analysis and systematic review of literature. J Am Coll Cardiol 2013; 61: 1585-1595.
41. Nietlispach F, Maisano F, Sorajja P, Leon MB, Rihal C, Feldman T. Percutaneous paravalvular leak closure: chasing the chameleon. Eur Heart J 2016; 37: 3495-3502.
42. Ussia GP, Barbanti M, Ramondo A, et al. The valve-in-valve technique for treatment of aortic bioprosthesis malposition an analysis of incidence and 1-year clinical outcomes from the Italian CoreValve registry. J Am Coll Cardiol 2011; 57: 1062-1068.
43. Moreno R, Dobarro D, Lopez de Sa E, et al. Cause of complete atrioventricular block after percutaneous aortic valve implantation: insights from a necropsy study. Circulation 2009; 120: e29-e30.
44. Wendler O, Schymik G, Treede H, et al. SOURCE 3 Registry: design and 30-day results of the European postapproval registry of the latest generation of the SAPIEN 3 transcatheter heart valve. Circulation 2017; 135: 1123-1132.
45. Sorajja P, Kodali S, Reardon MJ, et al. Outcomes for the commercial use of self-expanding prostheses in transcatheter aortic valve replacement: a report from the STS/ACC TVT registry. JACC Cardiovasc Interv 2017; 10: 2090-2098.
46. Hoffmann G, Lutter G, Cremer J. Durability of bioprosthetic cardiac valves. Dtsch Arztebl Int 2008; 105: 143-148.
47. Webb JG, Mack MJ, White JM, et al. Transcatheter aortic valve implantation within degenerated aortic surgical bioprostheses: PARTNER 2 Valve-in-Valve Registry. J Am Coll Cardiol 2017; 69: 2253-2262.
48. Puri R, Chamandi C, Rodriguez-Gabella T, Rodes-Cabau J. Future of transcatheter aortic valve implantation - evolving clinical indications. Nat Rev Cardiol 2018; 15: 57-65.
49. Eggebrecht H, Mehta RH. Transcatheter aortic valve implantation (TAVI) in Germany 2008–2014: on its way to standard therapy for aortic valve stenosis in the elderly? EuroIntervention 2016; 11: 1029-1033.
50. Walters DL, Webster M, Pasupati S, et al. Position statement for the operator and institutional requirements for a transcatheter aortic valve implantation (TAVI) program. Heart Lung Circ 2015; 24: 219-223.

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Editorials

Why are women with ST-elevation myocardial infarction treated differently to men?

Andrew I MacIsaac and Gemma Figtree

Med J Aust 2018; 209 (3): . || doi: 10.5694/mja18.00476
Published online: 6 August 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Cardiovascular diseases

Women's health

STEMI and coronary artery disease are major but underappreciated killers of Australian women

This issue of the Journal includes confronting data about inequities in the treatment and outcomes for men and women with ST-elevation myocardial infarction (STEMI).1 Khan and colleagues report that the 6-month mortality for women presenting with STEMI is twice that of men, a difference that persists after statistical correction for age and comorbid conditions. The article relates worrying evidence of a disparity in the delivery of evidence-based treatment, raising many important questions: What barriers are preventing women from presenting for treatment earlier? Why are there delays in providing women with recognised life-saving treatments? Why are women as a group treated less intensively than men despite having higher Global Registry of Acute Coronary Events (GRACE) risk scores? What biological differences require distinct therapeutic approaches and dedicated clinical trials?

1 St Vincent's Hospital Melbourne, Melbourne, VIC
2 Kolling Institute of Medical Research, Sydney, NSW

Correspondence: andrew.macisaac@svha.org.au

Competing interests:

No relevant disclosures.

1. 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.
2. Heart Foundation. 2018. Women and heart disease. 2018. https://www.heartfoundation.org.au/your-heart/women-and-heart-disease (viewed 21 June 2018).
3. Wei J, Mehta PK, Grey E, et al. Sex-based differences in quality of care and outcomes in a health system using a standardized STEMI protocol. Am Heart J 2017; 191: 30-36.
4. Chew DP, Scott IA, Cullen L, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. Med J Aust 2016; 205: 128-133. <MJA full text>
5. Bavishi C, Bangalore S, Patel D, et al. Short and long-term mortality in women and men undergoing primary angioplasty: a comprehensive meta-analysis. Int J Cardiol 2015; 198: 123-130.
6. Bugiardini R, Ricci B, Cenko E, et al. Delayed care and mortality among women and men with myocardial infarction. J Am Heart Assoc 2017; 6: doi: 10.1161/JAHA.117.005968.
7. Zimmermann S, Ruthrof S, Nowak K, et al. Short-term prognosis of contemporary interventional therapy of ST-elevation myocardial infarction: does gender matter? Clin Res Cardiol 2009; 98: 709-715.
8. Vaccarino V, Parsons L, Peterson ED, et al. Sex differences in mortality after acute myocardial infarction: changes from 1994 to 2006. Arch Intern Med 2009; 169: 1767-1774.

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Perspectives

Potential implications of the new American hypertension guidelines in Australia

Garry LR Jennings, Bronwyn A Kingwell and Erin Hoare

Med J Aust 2018; 209 (3): . || doi: 10.5694/mja18.00104
Published online: 6 August 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Cardiovascular diseases

Pharmaceutical preparations

Environment and public health

There are significant population health and economic implications if Australia were to adopt recently revised American guidelines

There are few things more controversial in medicine than when authoritative bodies shift the goalposts for common conditions and redefine normal values. This is particularly the case when the normative values for common chronic disease risk factors in the community, such as blood pressure or cholesterol, are made more stringent. In the stroke of a pen, millions of people have a disease or a risk factor they did not have the day before. Is this “the medicalisation of life” referred to by Illich?1

1 University of Sydney, Sydney, NSW
2 Baker Heart and Diabetes Institute, Melbourne, VIC
3 Food and Mood Centre, Deakin University, Geelong, VIC
4 Centre for Innovation in Mental and Physical Health and Clinical Treatment, Deakin University, Geelong, VIC

Correspondence: garry.jennings@sydney.edu.au

Acknowledgements:

This work was supported by funding from the Australian National Health and Medical Research Council (NHMRC) (Program Grant #1036352, and Centre for Research Excellence Grant #1000986) and the Victorian Government’s Operational Infrastructure Support Program (Garry Jennings and Bronwyn Kingwell). Erin Hoare was supported by an Australian Rotary Health Postdoctoral Research Fellowship. Bronwyn Kingwell was supported by an NHMRC Senior Principal Research Fellowship (NHMRC #1059454).

Competing interests:

Garry Jennings is Chief Medical Advisor of the Heart Foundation.

1. Illich I. Medical nemesis: the expropriation of health. New York: Pantheon Books, 1976.
2. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017; 13: 24430.
3. Maddox TM, Borden WB, Tang F, et al. Implications of the 2013 ACC/AHA cholesterol guidelines for adults in contemporary cardiovascular practice: insights from the NCDR PINNACLE registry. J Am Coll Cardiol 2014; 64: 2183-2192.
4. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. Guidelines for preventing and treating vitamin D deficiency and insufficiency revisited. J Clin Endocrinol Metab 2012; 97: 1153-1158.
5. SPRINT Research Group. A randomized trial of intensive versus standard blood- pressure control. N Engl J Med 2015; 373: 2103-2116.
6. Muntner P, Carey RM, Gidding S, et al. Potential US population impact of the 2017 ACC/AHA high blood pressure guideline. J Am Coll Cardiol 2018; 71: 109-118.
7. Gabb GM, Mangoni AA, Anderson CS, et al. Guideline for the diagnosis and management of hypertension in adults — 2016. Med J Aust 2016; 205: 85-89. <MJA full text>
8. Wang JG, Liu L. Global impact of 2017 American College of Cardiology/American Heart Association Hypertension guidelines: a perspective from China. Circulation 2018; 137: 546-548.
9. Schiffrin EL. Global impact of the 2017 American College of Cardiology/American Heart Association Hypertension guidelines: a perspective from Canada. Circulation 2018; 137: 883-885.
10. Wander GS, Ram CVS. Global impact of the 2017 American College of Cardiology/American Heart Association Hypertension guidelines: a perspective from India. Circulation 2018; 137: 549-550.
11. Australian Bureau of Statistics. National Health Survey: first results, 2014–15 (Cat. No. 4364.0.55.001). Canberra: ABS, 2015. http://www.abs.gov.au/ausstats/abs@.nsf/mf/4364.0.55.001 (viewed May 2018).
12. Hoare E, Kingwell BA, Jennings GLR. Blood pressure Down Under, but down under what? US and Australian hypertension guideline conversation. Hypertension 2018; 71: 972-975.
13. Gee ME, Campbell N, Sarrafzadegan N, et al. Standards for the uniform reporting of hypertension in adults using population survey data: recommendations from the World Hypertension League Expert Committee. J Clin Hypertens (Greenwich) 2014; 16: 773-781.
14. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey; 2013–2014 data documentation, codebook, and frequencies; blood pressure [website]. Atlanta, GA: CDC, 2015. https://wwwn.cdc.gov/Nchs/Nhanes/2013-2014/BPX_H.htm (viewed Mar 2018).
15. National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk. Melbourne: National Stroke Foundation, 2012. https://www.heartfoundation.org.au/images/uploads/publications/Absolute-CVD-Risk-Full-Guidelines.pdf (viewed May 2018).
16. Karakaya G, Van Tielen R, Umbach I. [OP.6C.02] Risk factors associated with medication non-compliance in arterial hypertension. J Hypertens 2016; 34: e72.
17. American Academy of Family Physicians. Guidelines developed by external organizations not endorsed by the AAFP [website]. AAFP, 2017. https://www.aafp.org/patient-care/clinical-recommendations/non-endorsed.html (viewed Mar 2018).
18. Hoare E, Stavreski B, Kingwell BA, Jennings GL. Australian adults’ behaviours, knowledge and perceptions of risk factors for heart disease: a cross-sectional study. Prev Med Rep 2017; 8: 204-209.
19. Australian Institute of Health and Welfare. Australian burden of disease study: impact and causes of illness and death in Australia 2011. Canberra: AIHW, 2016. https://www.aihw.gov.au/getmedia/d4df9251-c4b6-452f-a877-8370b6124219/19663.pdf.aspx?inline=true (viewed May 2018).
20. Rose G. Sick individuals and sick populations. Int J Epidemiol 2001; 30: 427-432.

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Perspectives

Glycaemic control apps for diabetes: lifting the lid

Rahul Barmanray and Esther Briganti

Med J Aust 2018; 209 (10): . || doi: 10.5694/mja18.00066
Published online: 30 July 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Endocrine system diseases

Information science

Pharmaceutical preparations

Ethics and law

The rapidly expanding diabetes app market presents new challenges for patients, health care providers and regulators

The medical technology industry’s explosive growth has set the stage for medical mobile applications (apps) to assist with the management of many chronic diseases. Diabetes mellitus is the archetypal example: its management requires optimising diet, physical activity, blood glucose self-monitoring, and safe medication use. As a multifaceted condition affecting so many people, diabetes is the perfect target for developers of medical apps to realise the promise of the digital revolution.

1 Royal Melbourne Hospital, Melbourne, VIC
2 Monash University, Melbourne, VIC

Correspondence: rahul.barmanray@mh.org.au

Competing interests:

No relevant disclosures.

1. Wu Y, Yao X, Vespasiani G, et al. Mobile app-based interventions to support diabetes self-management: a systematic review of randomized controlled trials to identify functions associated with glycemic efficacy. JMIR Mhealth Uhealth 2017; 5: e35.
2. Arnhold M, Quade M, Kirch W. Mobile applications for diabetics: a systematic review and expert-based usability evaluation considering the special requirements of diabetes patients age 50 years or older. J Med Internet Res 2014; 16: e104.
3. Bonoto BC, de Araújo VE, Godói IP, et al. Efficacy of mobile apps to support the care of patients with diabetes mellitus: a systematic review and meta-analysis of randomized controlled trials. JMIR Mhealth Uhealth 2017; 5: e4.
4. Chaudhury A, Duvoor C, Reddy Dendi VS, et al. Clinical review of antidiabetic drugs: implications for type 2 diabetes mellitus management. Front Endocrinol (Lausanne) 2017; 8: 6.
5. Rossi MC, Nicolucci A, Lucisano G, et al; DID Study Group. Impact of the “Diabetes Interactive Diary” telemedicine system on metabolic control, risk of hypoglycemia, and quality of life: a randomized clinical trial in type 1 diabetes. Diabetes Technol Ther 2013; 15: 670-679.
6. Charpentier G, Benhamou PY, Dardari D, et al; TeleDiab Study Group. The Diabeo software enabling individualized insulin dose adjustments combined with telemedicine support improves HbA1c in poorly controlled type 1 diabetic patients: a 6-month, randomized, open-label, parallel-group, multicenter trial (TeleDiab 1 Study). Diabetes Care 2011; 34: 533-539.
7. Huckvale K, Adomaviciute S, Prieto JT, et al. Smartphone apps for calculating insulin dose: a systematic assessment. BMC Med 2015; 13: 106.
8. Therapeutic Goods Administration. Australian regulatory guidelines for medical devices (ARGMD), section 5. Conformity assessment overview V1.1 May 2011. https://www.tga.gov.au/sites/default/files/devices-argmd-p1-01.pdf (viewed July 2018).
9. Sansom L, Delaat W, Horvath J. Review of medicines and medical devices regulation: report on the regulatory framework for medicines and medical devices. (Sansom Review; Stage One) March 2015. Commonwealth of Australia; 2015.
10. European Commission. Regulatory Framework. Regulation (EU) 2017/745 of the European Parliament and of the Council of 5 April 2017 on medical devices, amending Directive 2001/83/EC, Regulation (EC) No 178/2002 and Regulation (EC) No 1223/2009 and repealing Council Directives 90/385/EEC and 93/42/EEC. https://ec.europa.eu/growth/sectors/medical-devices/regulatory-framework_en (viewed Jan 2018).

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Narrative review

Thyroid nodules: diagnosis and management

Rosemary Wong, Stephen G Farrell and Mathis Grossmann

Med J Aust 2018; 209 (2): . || doi: 10.5694/mja17.01204
Published online: 16 July 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Endocrine system diseases

Summary

Thyroid nodules are common. Their importance lies in the need to assess thyroid function, degree of and future risk of mass effect, and exclude thyroid cancer, which occurs in 7–15% of thyroid nodules.
There are four key components to thyroid nodule assessment: clinical history and examination, serum thyroid stimulating hormone (TSH) measurement, ultrasound and, if indicated, fine-needle aspiration (FNA).
If the serum TSH is suppressed, a thyroid scan with ⁹⁹Tc can distinguish between a solitary hot nodule, a toxic multinodular goitre or, less commonly, thyroiditis or Graves’ disease within a coexisting nodular thyroid. Scintigraphically cold nodules are evaluated in the same way as in the setting of normal or elevated serum TSH levels.
Thyroid ultrasonography should be performed only for palpable goitre and thyroid nodules and by specialists with expertise in thyroid sonography.
Routine thyroid cancer screening is not recommended, except in high risk individuals, as the detection of early thyroid cancer has not been shown to improve survival.
FNA may be performed for nodules ≥ 1.0 cm depending on clinical and sonographic risk factors for thyroid cancer.
FNA specimens should be read by an experienced cytopathologist and be reported according to the Bethesda Classification System.
Molecular analysis of indeterminate FNA samples has potential to better discriminate benign from malignant nodules and thus guide management.
Surgery is indicated for FNA findings of malignancy or indeterminate cytology when there is a high risk clinical context. Surgery may also be indicated for suspicion of malignancy; larger nodules, especially with symptoms of mass effect; and in some patients with thyrotoxicosis.

1 Eastern Health, Melbourne, VIC
2 Austin Health, Melbourne, VIC
3 St Vincent's Hospital, Melbourne, VIC
4 University of Melbourne, Melbourne, VIC

Correspondence: mathisg@unimelb.edu.au

Competing interests:

No relevant disclosures.

1. Burman KD, Wartofsky L. Clinical practice. Thyroid nodules. N Engl J Med 2015; 373: 2347-2356.
2. Walsh JP. Managing thyroid disease in general practice. Med J Aust 2016; 205: 179-184. <MJA full text>
3. Soelberg KK, Bonnema SJ, Brix TH, Hegedüs L. Risk of malignancy in thyroid incidentalomas detected by 18F-fluorodeoxyglucose positron emission tomography: a systematic review. Thyroid 2012; 22: 918-925.
4. Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association Guidelines Task Force on thyroid nodules and differentiated thyroid cancer. Thyroid 2016; 26: 1-133.
5. Cancer Australia. Thyroid cancer statistics. Commonwealth of Australia; 2014. https://thyroid-cancer.canceraustralia.gov.au/statistics (viewed Nov 2017).
6. Grani G, Lamartina L, Durante C, et al. Follicular thyroid cancer and Hürthle cell carcinoma: challenges in diagnosis, treatment, and clinical management. Lancet Diabetes Endocrinol 2018; 6: 500-514.
7. Mazzaferri EL. Management of a solitary thyroid nodule. N Engl J Med 1993; 328: 553-559.
8. Angell TE, Vyas C, Medici M, et al. Differential growth rates of benign versus malignant thyroid nodules. J Clin Endocrinol Metab 2017; 102: 4642-4647.
9. Durante C, Costante G, Lucisano G, et al. The natural history of benign thyroid nodules. JAMA 2015; 313: 926-935.
10. Sosa JA, Duh QY, Doherty G. Striving for clarity about the best approach to thyroid cancer screening and treatment: is the pendulum swinging too far? JAMA Surg 2017; 152: 721-722.
11. US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for thyroid cancer: US Preventive Services Task Force recommendation statement. JAMA 2017; 317: 1882-1887.
12. Chen AY, Jemal A, Ward EM. Increasing incidence of differentiated thyroid cancer in the United States, 1988–2005. Cancer 2009; 115: 3801-3807.
13. Pandeya N, McLeod DS, Balasubramaniam K, et al. Increasing thyroid cancer incidence in Queensland, Australia 1982–2008 — true increase or overdiagnosis? Clin Endocrinol (Oxf) 2016; 84: 257-264.
14. Lim H, Devesa SS, Sosa JA, et al. Trends in thyroid cancer incidence and mortality in the United States, 1974–2013. JAMA 2017; 317: 1338-1348.
15. Kitahara CM, Sosa JA. The changing incidence of thyroid cancer. Nat Rev Endocrinol 2016; 12: 646-653.
16. Schneider AB, Ron E, Lubin J, et al. Dose-response relationships for radiation-induced thyroid cancer and thyroid nodules: evidence for the prolonged effects of radiation on the thyroid. J Clin Endocrinol Metab 1993; 77: 362-369.
17. Curtis RE, Rowlings PA, Deeg HJ, et al. Solid cancers after bone marrow transplantation. N Engl J Med 1997; 336: 897-904.
18. Shibata Y, Yamashita S, Masyakin VB, et al. 15 years after Chernobyl: new evidence of thyroid cancer. Lancet 2001; 358: 1965-1966.
19. Samuels MH. Subacute, silent, and postpartum thyroiditis. Med Clin North Am 2012; 96: 223-233.
20. Knobel M. Etiopathology, clinical features, and treatment of diffuse and multinodular nontoxic goiters. J Endocrinol Invest 2016; 39: 357-373.
21. Boelaert K, Horacek J, Holder RL, et al. Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules investigated by fine-needle aspiration. J Clin Endocrinol Metab 2006; 91: 4295-4301.
22. Haymart MR, Repplinger DJ, Leverson GE, et al. Higher serum thyroid stimulating hormone level in thyroid nodule patients is associated with greater risks of differentiated thyroid cancer and advanced tumor stage. J Clin Endocrinol Metab 2008; 93: 809-814.
23. Wells SA, Asa SL, Dralle H, et al. Revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma. Thyroid 2015; 25: 567-610.
24. Hoang JK, Lee WK, Lee M, et al. US Features of thyroid malignancy: pearls and pitfalls. Radiographics 2007; 27: 847-860; discussion 861-865.
25. Brito JP, Gionfriddo MR, Al Nofal A, et al. The accuracy of thyroid nodule ultrasound to predict thyroid cancer: systematic review and meta-analysis. J Clin Endocrinol Metab 2014; 99: 1253-1263.
26. Remonti LR, Kramer CK, Leitão CB, et al. Thyroid ultrasound features and risk of carcinoma: a systematic review and meta-analysis of observational studies. Thyroid 2015; 25: 538-550.
27. Bonavita JA, Mayo J, Babb J, et al. Pattern recognition of benign nodules at ultrasound of the thyroid: which nodules can be left alone? AJR Am J Roentgenol 2009; 193: 207-213.
28. Tessler FN, Middleton WD, Grant EG, et al. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): white paper of the ACR TI-RADS Committee. J Am Coll Radiol 2017; 14: 587-595.
29. Tsirona S, Vlassopoulou V, Tzanela M, et al. Impact of early vs late postoperative radioiodine remnant ablation on final outcome in patients with low-risk well-differentiated thyroid cancer. Clin Endocrinol (Oxf) 2014; 80: 459-463.
30. Suman P, Wang CH, Abadin SS, et al. Timing of radioactive iodine therapy does not impact overall survival in high-risk papillary thyroid carcinoma. Endocr Pract 2016; 22: 822-831.
31. Topliss D. Thyroid incidentaloma: the ignorant in pursuit of the impalpable. Clin Endocrinol (Oxf) 2004; 60: 18-20.
32. Yap NS, Maher R, Learoyd DL. Any detectable thyroglobulin in lymph node biopsy washouts suggests local recurrence in differentiated thyroid cancer. Endocr Connect 2014; 3: 150-155.
33. Cibas ES, Ali SZ, National Cancer Institute Thyroid FNA State of the Science Conference. The Bethesda System for reporting thyroid cytopathology. Am J Clin Pathol 2009; 132: 658-665.
34. Tamhane S, Gharib H. Thyroid nodule update on diagnosis and management. Clin Diabetes Endocrinol 2016; 2: 17.
35. Baloch ZW, Cibas ES, Clark DP, et al. The National Cancer Institute thyroid fine needle aspiration state of the science conference: a summation. CytoJournal 2008; 5: 6.
36. Oertel YC, Miyahara-Felipe L, Mendoza MG, Yu K. Value of repeated fine needle aspirations of the thyroid: an analysis of over ten thousand FNAs. Thyroid 2007; 17: 1061-1066.
37. Bongiovanni M, Spitale A, Faquin WC, et al. The Bethesda System for reporting thyroid cytopathology: a meta-analysis. Acta Cytol 2012; 56: 333-339.
38. Giles WH, Maclellan RA, Gawande AA, et al. False negative cytology in large thyroid nodules. Ann Surg Oncol 2015; 22: 152-157.
39. Mond M, Alexiadis M, Eriksson N, et al. Nuclear receptor expression in human differentiated thyroid tumors. Thyroid 2014; 24: 1000-1011.
40. Zhang M, Lin O. Molecular testing of thyroid nodules: a review of current available tests for fine-needle aspiration specimens. Arch Pathol Lab Med 2016; 140: 1338-1344.
41. Alexander EK, Kennedy GC, Baloch ZW, et al. Preoperative diagnosis of benign thyroid nodules with indeterminate cytology. N Engl J Med 2012; 367: 705-715.
42. Labourier E, Shifrin A, Busseniers AE, et al. Molecular testing for miRNA, mRNA, and DNA on fine-needle aspiration improves the preoperative diagnosis of thyroid nodules with indeterminate cytology. J Clin Endocrinol Metab 2015; 100: 2743-2750.
43. Nikiforova MN, Wald AI, Roy S, et al. Targeted next-generation sequencing panel (ThyroSeq) for detection of mutations in thyroid cancer. J Clin Endocrinol Metab 2013; 98: E1852-E1860.
44. Nikiforov YE, Carty SE, Chiosea SI, et al. Highly accurate diagnosis of cancer in thyroid nodules with follicular neoplasm/suspicious for a follicular neoplasm cytology by ThyroSeq v2 next-generation sequencing assay. Cancer 2014; 120: 3627-3634.
45. Ito Y, Miyauchi A, Oda H. Low-risk papillary microcarcinoma of the thyroid: a review of active surveillance trials. Eur J Surg Oncol 2018; 44: 307-315.
46. Kamran SC, Marqusee E, Kim MI, et al. Thyroid nodule size and prediction of cancer. J Clin Endocrinol Metab 2013; 98: 564-570.
47. Wharry LI, McCoy KL, Stang MT, et al. Thyroid nodules (≥ 4 cm): can ultrasound and cytology reliably exclude cancer? World J Surg 2014; 38: 614-621.
48. Kwak JY, Koo H, Youk JH, et al. Value of US correlation of a thyroid nodule with initially benign cytologic results. Radiology 2010; 254: 292-300.
49. Herzon FS, Morris DM, Segal MN, et al. Coexistent thyroid cancer and pregnancy. Arch Otolaryngol Head Neck Surg 1994; 120: 1191-1193.
50. Moosa M, Mazzaferri EL. Outcome of differentiated thyroid cancer diagnosed in pregnant women. J Clin Endocrinol Metab 1997; 82: 2862-2866.
51. Gharib H, Papini E, Garber JR, et al. American Association of Clinical Endocrinologists, American College of Endocrinology, and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules — 2016 update. Endocr Pract 2016; 22: 622-639.
52. American Thyroid Association Taskforce on Radioiodine Safety; Sisson JC, Freitas J, McDougall IR, et al. Radiation safety in the treatment of patients with thyroid diseases by radioiodine 131I: practice recommendations of the American Thyroid Association. Thyroid 2011; 21: 335-346.

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Inequity amplified: climate change, the Australian farmer, and mental health

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A shift in scholarly publishing practices and the growing menace of predatory journals

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Screening for spinal muscular atrophy

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Transcatheter aortic valve implantation: a new standard of care

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Why are women with ST-elevation myocardial infarction treated differently to men?

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Potential implications of the new American hypertension guidelines in Australia

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Glycaemic control apps for diabetes: lifting the lid

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Thyroid nodules: diagnosis and management

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Chronic idiopathic constipation in adults: epidemiology, pathophysiology, diagnosis and clinical management

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Severe asthma: implementing game-changing science

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Inequity amplified: climate change, the Australian farmer, and mental health

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A shift in scholarly publishing practices and the growing menace of predatory journals

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Screening for spinal muscular atrophy

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Transcatheter aortic valve implantation: a new standard of care

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Why are women with ST-elevation myocardial infarction treated differently to men?

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Potential implications of the new American hypertension guidelines in Australia

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Glycaemic control apps for diabetes: lifting the lid

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Thyroid nodules: diagnosis and management

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Chronic idiopathic constipation in adults: epidemiology, pathophysiology, diagnosis and clinical management

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Severe asthma: implementing game-changing science

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Pagination