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Robert Ellis was supported by an Australian Government Research Training Scholarship.
No relevant disclosures.
A new approach better informs women and doctors about what assisted reproductive technologies can achieve in 2017
Since the first Australian conceived by in vitro fertilisation (IVF) was born in 1980, this and other assisted reproductive technologies (ARTs) have come a long way in scope, availability, and success rates. About 4% of all Australian births are now made possible by ART,1 equivalent to one child in every classroom.
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Stephen Robson is a paid member of the Medical Benefits Schedule Review and provides in vitro fertilisation services, but does not own any shares in an IVF unit.
A standard approach in QT measurement improves communication between clinicians
An abnormally prolonged QT interval is associated with an increased risk of sudden cardiac death.1 Some professional bodies recommend national population-based screening programs to detect QT prolongation.2 Familial long QT syndrome (LQTS) may remain undetected because of misdiagnosis (eg, as a seizure disorder)3 or through failure to measure the QT interval correctly.4 Psychiatrists fear the QT prolongation caused by many psychotropic medications,5 and it may also be seen during periods of hypothermia; electrolyte imbalance (such as hypokalaemia, hypomagnesaemia and hypocalcaemia); in the setting of raised intracranial pressure or post-cardiac arrest; with other medications, such as type 1A, 1C and III antiarrhythmic agents; and with antihistamines and macrolide antibiotics.
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Jon Skinner has no relevant disclosures. Kathryn Waddell-Smith is supported by grants from the Green Lane Research and Educational Fund and the National Heart Foundation, New Zealand.
Evidence mounts for a legal duty to disclose performance data as part of informed consent
Hospitals, colleges and other institutions increasingly collect, analyse and disseminate data relating to the performance of individual health practitioners, particularly those undertaking surgical procedures. Arguments have long been made for an ethical duty to disclose information regarding a practitioner’s experience or skill to patients as part of the process of informed consent (Box 1).1 Significantly, recent developments suggest that practitioners may, in some circumstances, have a legal duty to disclose their performance data to patients (Box 2).
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I am grateful to Bill Madden for his comments on earlier drafts of this article.
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Promoting the supply, distribution and sustainability of rural outreach services requires multilevel policy development and regional service planning
The need for more local specialist services to support rural communities is well established as a significant issue in Australia. Although the specialist workforce is growing, providers are increasingly choosing to subspecialise and work in metropolitan practice.1 Access to medical specialists in major cities is consistently high at 162.1 full-time equivalent specialists per 100 000 population, but diminishes for people living in inner or outer regional (82.7 and 61.5 per 100 000 respectively) and remote areas (34.2 per 100 000).2
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This publication used data from the MABEL longitudinal survey of doctors conducted by the University of Melbourne and Monash University (the MABEL research team). Funding for MABEL comes from the National Health and Medical Research Council (Health Services Research grant, 2008–2011; Centre for Research Excellence in Medical Workforce Dynamics, 2012–2016) with additional support from the Department of Health (2008) and Health Workforce Australia (2013). Belinda O’Sullivan was supported by a Postgraduate Publications Award from Monash University.
No relevant disclosures.
Objective: To describe the epidemiology, treatment and adverse events after snakebite in Australia.
Design: Prospective, multicentre study of data on patients with snakebites recruited to the Australian Snakebite Project (2005–2015) and data from the National Coronial Information System.
Setting, participants: Patients presenting to Australian hospitals with suspected or confirmed snakebites from July 2005 to June 2015 and consenting to participation.
Main outcome measures: Demographic data, circumstances of bites, clinical effects of envenoming, results of laboratory investigations and snake venom detection kit (SVDK) testing, antivenom treatment and adverse reactions, time to discharge, deaths.
Results: 1548 patients with suspected snakebites were enrolled, including 835 envenomed patients (median, 87 per year), for 718 of which the snake type was definitively established, most frequently brown snakes (41%), tiger snakes (17%) and red-bellied black snakes (16%). Clinical effects included venom-induced consumption coagulopathy (73%), myotoxicity (17%), and acute kidney injury (12%); severe complications included cardiac arrest (25 cases; 2.9%) and major haemorrhage (13 cases; 1.6%). There were 23 deaths (median, two per year), attributed to brown (17), tiger (four) and unknown (two) snakes; ten followed out-of-hospital cardiac arrests and six followed intracranial haemorrhages. Of 597 SVDK test results for envenomed patients with confirmed snake type, 29 (4.9%) were incorrect; 133 of 364 SVDK test results for non-envenomed patients (36%) were false positives. 755 patients received antivenom, including 49 non-envenomed patients; 178 (24%), including ten non-envenomed patients, had systemic hypersensitivity reactions, of which 45 (6%) were severe (hypotension, hypoxaemia). Median total antivenom dose declined from four vials to one, but median time to first antivenom was unchanged (4.3 hours; IQR, 2.7–6.3 hours).
Conclusions: Snake envenoming is uncommon in Australia, but is often severe. SVDKs were unreliable for determining snake type. The median antivenom dose has declined without harming patients. Improved early diagnostic strategies are needed to reduce the frequently long delays before antivenom administration.
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Geoffrey Isbister is supported by a National Health and Medical Research Council (NHMRC) Senior Research Fellowship (1061041). Nicole Ryan is supported by an NHMRC Early Career Fellowship. Colin Page is funded by a Queensland Emergency Medicine Research Foundation Fellowship. The study described in this article is funded by an NHMRC Centre for Research Excellence Grant (1110343). We acknowledge the help of numerous critical care nurses and medical staff who assisted in recruiting patients to the study, and the local investigators at hospitals around Australia.
Christopher Johnston is employed by Boehringer Ingelheim; this research was independent of his employment by Boehringer Ingelheim.
Objectives: To estimate cumulative live birth rates (CLBRs) following repeated assisted reproductive technology (ART) ovarian stimulation cycles, including all fresh and frozen/thaw embryo transfers (complete cycles).
Design, setting and participants: Prospective follow-up of 56 652 women commencing ART in Australian and New Zealand during 2009–2012, and followed until 2014 or the first treatment-dependent live birth.
Main outcome measures: CLBRs and cycle-specific live birth rates were calculated for up to eight cycles, stratified by the age of the women (< 30, 30–34, 35–39, 40–44, > 44 years). Conservative CLBRs assumed that women discontinuing treatment had no chance of achieving a live birth if had they continued treatment; optimal CLBRs assumed that they would have had the same chance as women who continued treatment.
Results: The overall CLBR was 32.7% (95% CI, 32.2–33.1%) in the first cycle, rising by the eighth cycle to 54.3% (95% CI, 53.9–54.7%) (conservative) and 77.2% (95% CI, 76.5–77.9%) (optimal). The CLBR decreased with age and number of complete cycles. For women who commenced ART treatment before 30 years of age, the CLBR for the first complete cycle was 43.7% (95% CI, 42.6–44.7%), rising to 69.2% (95% CI, 68.2–70.1%) (conservative) and 92.8% (95% CI, 91.6–94.0) (optimal) for the seventh cycle. For women aged 40–44 years, the CLBR was 10.7% (95% CI, 10.1–11.3%) for the first complete cycle, rising to 21.0% (95% CI, 20.2–21.8%) (conservative) and 37.9% (95% CI, 35.9–39.9%) (optimal) for the eighth cycle.
Conclusion: CLBRs based on complete cycles are meaningful estimates of ART success, reflecting contemporary clinical practice and encouraging safe practice. These estimates can be used when counselling patients and to inform public policy on ART treatment.
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The Fertility Society of Australia funds the Australian and New Zealand Assisted Reproductive Database (ANZARD). We acknowledge the provision of data to ANZARD by Australian and New Zealand fertility clinics.
The Fertility Society of Australia funds the National Perinatal Epidemiology and Statistics Unit to manage ANZARD and conduct national reporting of ART in Australia and New Zealand. Georgina Chambers is employed by the University of New South Wales (UNSW) and is director of the National Perinatal Epidemiology and Statistics Unit at UNSW. She has received an institutional research grant unrelated to this study from the Australian Research Council for which Virtus Health, a publicly listed IVF company, was the partner organisation (2010–2013). Clare Boothroyd owns a facility that offers ART, and has received funding from MSD, Merck-Serono, and Ferring for work unrelated to this article. Luk Rombauts has a minority shareholding in the Monash IVF Group, a publicly listed IVF company, and has received funding from MSD, Merck-Serono, and Ferring for work unrelated to this article. Michael Chapman has a minority shareholding in Virtus Health, and has received funding from MSD, Merck-Serono, and Ferring for work unrelated to this article.
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Michael Low is employed by Monash Health and funded by a Royal Australasian College of Physicians (RACP) National Health and Medical Research Council (NHMRC) CRB Blackburn Scholarship. George Grigoriadis is employed by Monash Health and Alfred Health and funded by a Victorian Cancer Agency Clinical Research Fellowship. We thank Shahla Vilcassim (Monash Haematology) for her help in attaining the figure in .
No relevant disclosures.
Objectives: To determine the rates at which people recently released from prison attend general practitioners, and to describe service users and their encounters.
Design, participants and setting: Prospective cohort study of 1190 prisoners in Queensland, interviewed up to 6 weeks before expected release from custody (August 2008 – July 2010); their responses were linked prospectively with Medicare and Pharmaceutical Benefits Scheme data for the 2 years after their release. General practice attendance was compared with that of members of the general Queensland population of the same sex and in the same age groups.
Main outcome measures: Rates of general practice attendance by former prisoners during the 2 years following their release from prison.
Results: In the 2 years following release from custody, former prisoners attended general practice services twice as frequently (standardised rate ratio, 2.04; 95% CI, 2.00–2.07) as other Queenslanders; 87% of participants visited a GP at least once during this time. 42% of encounters resulted in a filled prescription, and 12% in diagnostic testing. Factors associated with higher rates of general practice attendance included history of risky opiate use (incidence rate ratio [IRR], 2.09; 95% CI, 1.65–2.65), having ever been diagnosed with a mental disorder (IRR, 1.32; 95% CI, 1.14–1.53), and receiving medication while in prison (IRR, 1.82; 95% CI, 1.58–2.10).
Conclusions: Former prisoners visited general practice services with greater frequency than the general Queensland population. This is consistent with their complex health needs, and suggests that increasing access to primary care to improve the health of former prisoners may be insufficient, and should be accompanied by improving the quality, continuity, and cultural appropriateness of care.
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We thank Queensland Corrective Services for assistance with data collection, and Passports study participants for sharing their stories. We acknowledge the Australian Government Department of Human Services as the source of Medicare and Pharmaceutical Benefits Scheme (PBS) records. The Passports study was funded by a National Health and Medical Research Council (NHMRC) Strategic Award (409966). The HIP-Aus study is funded by a National Health and Medical Research Council Project grant (1002463). Stuart Kinner is supported by an NHMRC Senior Research Fellowship (APP1078168). The views expressed in this article are solely those of the authors, and in no way reflect the views or policies of Queensland Corrective Services.
No relevant disclosures.
Abstract
Objectives: Faecal microbiota transplantation (FMT) has emerged as a useful approach for treating Clostridium difficile-associated diarrhoea (CDAD). Randomised controlled trials (RCTs) have recently evaluated its effectiveness, but systematic reviews have focused on evidence from case series. We therefore conducted a systematic review and meta-analysis of RCTs evaluating the effectiveness of FMT for treating CDAD.
Study design: We included RCTs that primarily recruited adults with CDAD and compared the effectiveness of FMT with that of placebo, antibiotic therapy, or autologous stool transplantation, or compared different preparations or modes of delivery of FMT. Dichotomous symptom data were pooled to calculate a relative risk (RR) of CDAD persisting after therapy, and the number needed to treat (NNT).
Data sources: MEDLINE, EMBASE, and the Cochrane Controlled Trials Register and Database of Systematic Reviews were searched to 6 February 2017.
Data synthesis: We identified ten RCTs that evaluated the treatment of a total of 657 patients with CDAD. Five RCTs compared FMT with placebo (including autologous FMT) or vancomycin treatment (total of 284 patients); FMT was statistically significantly more effective (RR, 0.41; 95% CI, 0.22–0.74; NNT, 3; 95% CI, 2–7). Heterogeneity across studies was significant (I2 = 61%); this heterogeneity was attributable to the mode of delivery of FMT, and to the therapy being more successful in European than in North American trials. The other five RCTs evaluated different approaches to FMT therapy. Frozen FMT preparations were as efficacious as fresh material in one RCT, but the numbers of patients in the remaining RCTs were too small to allow definitive conclusions.
Conclusions: Moderate quality evidence from RCT trials indicates that FMT is more effective in patients with CDAD than vancomycin or placebo. Further investigations are needed to determine the best route of administration and FMT preparation.