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Feature Articles

Is mandatory pre-procedure ultrasound viewing before termination of pregnancy ethical?

Sally is a pregnant nineteen year old woman at eight weeks gestation. Sally is currently serving time in gaol and has arrived at the hospital gynaecology clinic with several members of Justice Health.

Sally is informed that the hospital can offer surgical termination of pregnancy and she is advised about the possible complications and risks of the procedure. Upon hearing these, Sally becomes tearful. The doctor advises Sally that she should not terminate the pregnancy if she has any uncertainties. Sally explains that she is concerned about the risks of the procedure, but still wants to go ahead with the termination.

As part of her initial assessment, the doctor performs an ultrasound. The consultant points out the fetal poles and heartbeat stating, “Here is the baby’s heart beating.” Upon hearing this, Sally begins crying and becomes withdrawn, not responding to any questions. The doctor concludes that Sally should be given more time to contemplate whether she wants to terminate this pregnancy and does not book her in for the procedure.

The above clinical example raises a number of ethical issues in regards to abortion. Can the woman make an informed choice without coercion when she is shown the ultrasound in this manner? Is the autonomy of the patient compromised when she is forced to listen or view information that is not necessary to her medical care? Is it in the patient’s best interest to show her the ultrasound without first asking her preference? In this article I will focus on the medical ethical values of autonomy, informed consent and beneficence in regards to the use of pre-procedure ultrasound for abortion…

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Guest Articles

Where do new clinical treatments come from? – Ian Frazer

Figure 1. The Outdoor Room – a focus for collaborative activity (© Wilson Architects and Donovan Hill. Reproduced with permission).
Figure 1. The Outdoor Room – a focus for collaborative activity (© Wilson Architects and Donovan Hill. Reproduced with permission).

According to the Australian Institute of Health and Welfare, we gained over 25 years of extra life expectancy during the 20th century. These extra years have resulted largely from development of public health measures, vaccines and antibiotics that have reduced the impact of infectious diseases on a global basis. These interventions are the tangible result of medical research conducted by health care professionals and scientists worldwide. Over the last 100 years, there has been a slow but steady revolution in the way that medical research is conducted. What was once the province of hobby scientists, working alone in spare time and using their own funds, in lab space hidden away in hospitals and medical schools, has become a multi-million dollar business, conducted in large biomedical research institutes by professionally trained government and industry funded scientists and clinician scientists. Why has this change come about, and where is this leading?

The early drivers of medical research were the desire of the health care professions to ensure better health outcomes for their patients, and the curiosity of scientists about human physiology and pathophysiology, and these remain relevant today. However, as the technologies available for research have become more sophisticated, and the existing knowledge base more extensive, research has required more prior education, more sophisticated facilities, more collaboration, and more money. Further, the funding model for universities, the traditional trainers of researchers, has changed to one driven by quantity of throughput in addition to quality of output. In consequence, further drivers have emerged which have encouraged a more commercial and managed approach to research. These include desire of universities to maximise student numbers and research grants, government desire to see outcomes from research at affordable prices, and a growing “for profit” pharmaceutical industry hungry for the next blockbuster product, that might be expected to sell over $1billion per annum in the first years of launch. These drivers have increasingly led to focusing of research into institutes that can compete on a world playing field for resources and talent, and can afford the increasingly sophisticated infrastructure of the large scale “hypothesis free” approach to biology currently being practiced.

These drivers will likely continue to influence the conduct of medical research in the first decades of the 21st century, though some new ones have recently emerged. The supply of blockbuster drugs has largely dried up, at a time when many of the major successes of recent years…

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Review Articles

Prostate cancer: Past, present and future Australian initiatives for improving men’s health

Abstract

Prostate cancer is the most common internal cancer in Australian men. Whilst recent trends demonstrate stabilising incidence and decreasing mortality rates, it remains a major health burden for Australian men and requires continued action. This report outlines the status of prostate cancer in Australia’s health care system, both past and present, and analyses the effectiveness of healthcare campaigns used to generate awareness. The aim is to assess awareness, perception and public behaviour toward this disease, as well as to impart Australia’s strategies on improving public knowledge in this area.

Methods: A comprehensive search of English language literature was conducted. Articles were limited to those relating to prostate cancer in Australia. Additionally, websites of various prostate cancer awareness campaigns or organisations were evaluated, based on a comprehensive list provided by the National Men’s Health Policy Submissions Document. [1]

Results: One hundred and ninety-five relevant journal articles were found, which were subsequently evaluated independently by three authors. Of these, 56 fit the inclusion criteria.

Conclusion: Development in knowledge, awareness and attitudes toward prostate cancer has been significant over the past few years. However, despite prostate cancer being a major health burden for Australian men, there are still misconceptions and a lack of awareness amongst the general population. The combination of prostate cancer specific organisations such as the Prostate Cancer Foundation of Australia, campaigns and events such as ‘Movember’ and ‘Be a Man,’ health promotion in schools, universities and workplaces, as well as the development of a national men’s health policy can only further serve to advance prostate cancer awareness.

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Review Articles

On the nature of the alcohol-based hand rub and its use for hand hygiene in medicine and healthcare

Abstract

Hand hygiene (HH) is today recognised as being the most important factor in preventing the spread of infections; however, adequate compliance with this remains unacceptably low amongst healthcare workers (HCWs). One of the leading products in the push for successful HH is the alcohol-based hand rub (ABHR), which currently exists as a ubiquitous item in healthcare facilities. This review amalgamates the current understanding of ABHRs, presenting an overview of important issues including its correct usage and insights into HH. Aimed at Australian HCWs and students, a small yet significant amount of attention is devoted to Hand Hygiene Australia – one of the leading authorities in this subject area. It may be concluded that the ABHR is an effective hand disinfectant that also improves HH compliance, and is thus highly recommended for use in healthcare settings.

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Review Articles

Stethoscopes as vectors of infections

Aim: To conduct a review of the literature to evaluate whether stethoscopes constitute a clinically significant vector of healthcareassociated infection, and to explore the behaviour, attitudes and beliefs about stethoscope hygiene amongst medical students. Methods: Section one: PubMed was searched for empirical studies written in English, published before 1 May 2010, dealing with colonisation rates of stethoscopes and self-reported frequency of stethoscope cleaning by healthcare staff. Thirty-one articles were systematically reviewed. Section two: Qualitative and quantitative cross-sectional study of medical students. A convenience sample of seventeen undergraduate medical students in years two, three and four were asked a series of thirteen questions exploring their knowledge, practice of and attitudes towards stethoscope hygiene. Results: The diaphragm and bell of stethoscopes are colonised with micro-organisms on average 87.3% of the time. On average, 14% of stethoscopes carry MRSA, and 16.5% carry gram-negative species. On average, 58.8% of doctors clean their stethoscope annually or never. Fifty-nine percent of students surveyed had never cleaned their stethoscope. Only 29% of students had ever been advised about stethoscope hygiene. Eighty-two percent of students felt senior colleagues had influenced their attitude (positive or negative) toward stethoscope hygiene. Conclusions: Stethoscopes potentially represent a moderate-to-high risk of infection transmission, particularly in vulnerable settings, yet stethoscope hygiene is rarely considered or practiced by doctors and medical students. Improving stethoscope hygiene in practice requires addressing the lack of formal education on the subject and the shortage of positive role models.

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Review Articles

Preventing vertical hepatitis B transmission across all borders: A review of current concepts

Aim: The aim of this review is to emphasise the global significance of Hepatitis B (HBV) and its vertical transmission, and to summarise the current status of preventative strategies. Methods: A literature review was carried out. PubMed, The Cochrane Collaboration and Medline were searched for both primary studies and reviews pertaining to vertical HBV transmission, its prevention and barriers to prevention. Key words used included “HBV,” “Hepatitis B,” “vertical transmission,” “mother to child transmission,” “prevention” and “epidemiology.” Results: HBV is a major cause of death from liver cancer and liver failure. HBV is the ninth leading cause of death internationally and accounts for up to 80% of the world’s primary liver cancers. In highly endemic areas, 75% of chronic HBV is acquired by vertical transmission (mother to child transmission at birth), or by horizontal transmission in early childhood. The earlier in life the disease is acquired, the greater the adverse consequences. Available therapies for preventing mother to child transmission are very effective and include multiple doses of HBV vaccine and usually, HBV immunoglobulin. However, up to 10% of infants acquire HBV despite this standard prophylaxis. Whether anti-viral agents should be given to mothers with a high viral load to prevent transmission remains controversial. Conclusion: HBV is an extremely important global public health issue. Prevention of vertical transmission is the most important preventative strategy and current prophylactic therapies are highly effective. Emerging approaches for mothers with a high viral load require further investigation to determine whether they are effective and safe. Developing countries face the issues of cost, access and education to apply prevention strategies, while developed countries need processes to ensure adherence to established recommendations.

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Review Articles

Causes of death in neonatal intensive care units

Introduction

Of the approximately 130 million babies born each year, an estimated four million babies die in the neonatal period. Globally, the main causes of death are estimated to be preterm birth (28%), severe infections (26%) and asphyxia (23%). [1] New South Wales (NSW) is the most populous state in Australia with approximately 86,000 births per year. In 2006, 6,044 babies in NSW were registered to neonatal intensive care units (NICUs), representing 2.3% of total live births in that year. [2] Gestational age is highly correlated with birth outcomes including mortality. Each extra week of time spent in utero increases an infant’s chances of survival significantly, and by 27 weeks of pregnancy, over 90% of infants will survive.

There are significant differences between common causes of death in the pre-term population (less than 37 weeks gestation) and the term population (37+ weeks gestation). The most notable difference is an approximate five-fold increase in deaths caused by congenital neurological malformations in the term population compared with the pre-term population [3]. Premature infants have a considerably higher chance of dying than full-term infants. However, improved neonatal care, particularly the widespread use of surfactant replacement and antenatal steroids, has almost halved neonatal mortality in many parts of the world. [1] Between 1985 and 1991 in the United States, the overall neonatal mortality rate declined from 5.4 to 4.0 per 1,000 live births. An understanding of causes of neonatal death and changes in mortality rates is critical for prenatal counselling, decision making, quality control and further improvement in management.

In NSW, newborn infants are admitted to NICUs under the following criteria: gestational age less than 32 weeks, birth weight less than 1,500 grams, need for mechanical ventilation for four hours or more, continuous positive airways pressure for four hours or more and/or major surgery, defined as opening of the body cavity.

Newborns admitted to NICUs are cared for by a highly specialised team of medical, nursing and allied health staff. Despite the level of sickness and intensity of morbidities of NICU patients, mortality rates are relatively low. Neonatal mortality rate is defined as the number of neonatal deaths per 1,000 live births and includes all deaths of infants within 28 days after birth. Each neonate who dies in the NICU represents not only a financial cost to the community but more importantly, a significant emotional stress and grief for the involved parents and staff…

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Guest Articles

Diagnostic modelling in General Practice – John Murtagh

Prof. John Murtagh

Introduction

All facets of the great profession of medicine are fascinating and that is basically the reason why I pursued a career in General Practice. It provides the opportunity to diagnose and manage diseases from A-Z (acne to zoonoses). Practising in a rural community, with the luxury of managing the local hospital, was the ideal environment for my interests and consequently I entered rural practice in partnership with my wife, Dr Jill Rosenblatt in 1969. As the only practitioners in the community of Neerim South we enjoyed considerable responsibility especially with the management of emergencies. The discipline of General Practice, however, is one of the most difficult and challenging of all the healing arts. General Practitioners are at the front line of patient care and have to manage presenting problems as they appear at any time and place.

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Guest Articles

How to enjoy your patients – Murray Longmore

We all want to be remembered for something – a major contribution to science, or a political triumph bringing peace to a beleaguered world, or perhaps you would like to be honoured with an eponymous syndrome? Or, more modestly, as one committed housewife said, “I would like simply to be remembered for making good gravy.” She held on to this humble desire until it was pointed out to her by some wit, that such a wish was really taking cannibalism too far. So what do we boil down to? If not exactly gravy, then perhaps a juicy bundle of conflicting desires encased in a will for pleasure. No philosopher, artist or scientist has been able to come up with a better reason for doing something than pleasure (giving it, and receiving it).

A world without pleasure is pointless. We may sense this pointlessness on a bad day as we go out to work, fighting stolidly to save impossible lives. But if we accord taking pleasure in our patients as a primary aim, all may not be lost. Of course we know that patients’ welfare and the relief of suffering should be our first concern. But this wears thin after a decade or two (or a week or two) at unpromising bedsides. Pleasure is the only motivator that lasts a professional lifetime. Like it or not, there is no alternative to pleasure. Just as the sex therapist must “give permission” to inhibited clients to enable them to partake of the full range of sexual pleasures, so medical authors have to give permission to fellow doctors to sample clinical pleasures. We are so conditioned by our objective scientific training that we tend to put pleasure last in the list of tasks we must accomplish – if it ever gets onto the list at all.

So what are the pleasures we are talking about? I was once told by a connoisseur, who happens to be a judge, that all pleasures are sensory (as he refilled my glass with a sumptuous wine). So “enjoying our patients” does sound rather cannibalistic in this context. While we do not exactly endorse this approach, it reminds us that swallowing is the vital precursor of many pleasures. And in the clinical context, this means swallowing the whole patient – hook, line and sinker. For those who do not fish, it may be necessary to point out that the sinker is…

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Guest Articles

The Exercise Paradox – Dennis Kuchar

Dr. Dennis L Kuchar

In 2009, a woman pleaded guilty to reckless homicide and faces up to five years in prison for exercising her husband to death in a swimming pool. He suffered a ‘heart attack.’ [1] We cannot know, however, whether this was an ischaemic event or an arrhythmia. Exercise is promoted and encouraged in society; it is considered a healthy pursuit with benefits to the heart and mind. We know that certain heart diseases make exercising dangerous, but what risk is exercise to a healthy person without known heart disease?

Ancient history records the death of the Greek messenger Phidippides who ran 26 miles from Marathon to Athens to deliver the news of the victory over Persian invaders, only to collapse and die soon after his arrival.

In the past few years we have heard of professional athletes collapsing during soccer and basketball games and on the athletics track. These are graphically represented and frequently viewed on YouTube. In September last year, Evander Sno, a midfielder for Dutch soccer giants, Ajax, suffered a cardiac arrest during a match. He was successfully resuscitated after four shocks from an external defibrillator – an outcome unfortunately not shared by several athletes in recent years.

Can these deaths be prevented?

Not so long ago, there was evidence to suggest that marathon runners were immune to coronary artery disease, [2] and this idea has pervaded public perception. If someone can compete in countless marathons and triathlons, how could they possibly be at risk of dying from a heart attack? This has been debunked however, with the finding that coronary disease is the major cause of exercise related deaths in the over 35 age group; a phenomenon also seen in younger individuals. [3] To confuse matters more, there is evidence that strenuous activity kills patients with known heart disease but the risk is reduced if they exercise on a regular basis compared with those who are sedentary. [4] To top it off, recent Australian research shows evidence of damage to the right ventricle detected by MRI following a triathlon in normal hearts. [5]

One of the problems in identifying athletes at risk is the similar appearances of the athletic heart to abnormal pathological hearts. Physiologic changes can occur which mimic the appearance of these conditions (so-called ‘athlete’s heart’). They can manifest as morphologic changes (such as wall thickening mimicking hypertrophic cardiomyopathy), ECG changes (usually voltage changes, non-specific…