ORCID Profile
0000-0002-6825-4440
Current Organisations
Alfred Health
,
Monash University
,
Monash Health
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Publisher: Bioscientifica
Date: 04-02-2017
DOI: 10.1530/EDM-16-0089
Abstract: A 58-year-old man with metastatic radioiodine-refractory differentiated thyroid cancer (DTC) presented with left thigh and right flank numbness. He had known progressive and widespread bony metastases, for which he received palliative radiotherapy, and multiple bilateral asymptomatic pulmonary metastases. CT scan and MRI of the spine revealed metastases at right T10–L1 vertebrae with extension into the central canal and epidural disease at T10 and T11 causing cord displacement and canal stenosis but retention of spinal cord signal. Spinal surgery was followed by palliative radiotherapy resulting in symptom resolution. Two months later, sorafenib received approval for use in Australia and was commenced and up-titrated with symptomatic management of mild adverse effects. Follow-up CT scan three months after commencement of sorafenib revealed regression of pulmonary metastases but no evident change in most bone metastases except for an advancing lesion eroding into the right acetabulum. The patient underwent a right total hip replacement, intra-lesional curettage and cementing. After six months of sorafenib therapy, CT scanning showed enlarging liver lesions with marked elevation of serum thyroglobulin. Lenvatinib was commenced and sorafenib was ceased. He now has stable disease with a falling thyroglobulin more than 5 years after metastatic radioiodine-refractory DTC was diagnosed. In DTC, 5% of distant metastases become radioiodine-refractory, resulting in a median overall survival of 2.5–3.5 years. Tyrosine kinase inhibitor (TKI) therapy has recently been demonstrated to increase progression-free survival in these patients but poses some unique management issues and is best used as part of an integrated approach with directed therapy. Directed therapies may have greater potential to control localised disease and related symptoms when compared to systemic therapies. Consider TKI therapy in progressive disease where benefits outweigh risks. Active surveillance and timely intervention are required for TKI-related adverse effects. There is a need for further research on the clinical application of TKI therapy in advanced DTC, including comparative efficacy, sequencing and identifying responders.
Publisher: BMJ
Date: 11-2020
DOI: 10.1136/BMJOPEN-2020-038845
Abstract: Gestational diabetes (GDM) is a common yet highly heterogeneous condition. The ability to calculate the absolute risk of adverse pregnancy outcomes for an in idual woman with GDM would allow preventative and therapeutic interventions to be delivered to women at high-risk, sparing women at low-risk from unnecessary care. The Prediction for Risk-Stratified care for women with GDM (PeRSonal GDM) study will develop, validate and evaluate the clinical utility of a prediction model for adverse pregnancy outcomes in women with GDM. We undertook formative research to conceptualise and design the prediction model. Informed by these findings, we will conduct a model development and validation study using a retrospective cohort design with participant data collected as part of routine clinical care across three hospitals. The study will include all pregnancies resulting in births from 1 July 2017 to 31 December 2018 coded for a diagnosis of GDM (estimated s le size 2430 pregnancies). We will use a temporal split-s le development and validation strategy. A multivariable logistic regression model will be fitted. The performance of this model will be assessed, and the validated model will also be evaluated using decision curve analysis. Finally, we will explore modes of model presentation suited to clinical use, including electronic risk calculators. This study was approved by the Human Research Ethics Committee of Monash Health (RES-19–0000713 L). We will disseminate results via presentations at scientific meetings and publication in peer-reviewed journals. Systematic review proceeding this work was registered on PROSPERO (CRD42019115223) and the study was registered on the Australian and New Zealand Clinical Trials Registry (ACTRN12620000915954) Pre-results.
Publisher: Oxford University Press (OUP)
Date: 08-2020
DOI: 10.1530/EJE-20-0401
Abstract: The COVID-19 pandemic has required rapid transformation and adaptation of healthcare services. Women with gestational diabetes mellitus (GDM) are one of the largest high-risk groups accessing antenatal care. In reformulating the care offered to those with GDM, there is a need to balance the sometimes competing requirement of lowering the risk of direct viral transmission against the potential adverse impact of service changes. We suggest pragmatic options for screening of GDM in a pandemic setting based on blood tests, and risk calculators applied to underlying risk factors. Alternative models for antenatal care provision for women with GDM, including targeting high-risk groups, early lifestyle interventions and remote monitoring are provided. Testing options and their timing for postpartum screening in women who had GDM are also considered. Our suggestions are only applicable in a pandemic scenario, and usual guidelines and care pathways should be re-implemented as soon as possible and appropriate.
Publisher: Bioscientifica
Date: 28-07-2016
DOI: 10.1530/EDM-16-0049
Abstract: Thyrotoxicosis is an under-recognised but clinically important complication of parathyroidectomy. We report a case of a 37-year-old man with tertiary hyperparathyroidism who initially developed unexplained anxiety, diaphoresis, tachycardia, tremor and hyperreflexia one day after subtotal parathyroidectomy. Thyroid biochemistry revealed suppressed thyroid stimulating hormone and elevated serum free T 4 and free T 3 levels. Technetium-99m scintigraphy scan confirmed diffusely decreased radiotracer uptake consistent with thyroiditis. The patient was diagnosed with thyrotoxicosis resulting from palpation thyroiditis. Administration of oral beta-adrenergic antagonists alleviated his symptoms and there was biochemical evidence of resolution fourteen days later. This case illustrates the need to counsel patients about thyroiditis as one of the potential risks of parathyroid surgery. It also emphasises the need for biochemical surveillance in patients with unexplained symptoms in the post-operative period and may help to minimise further invasive investigations for diagnostic clarification. Thyroiditis as a complication of parathyroidectomy surgery is uncommon but represents an under-recognised phenomenon. It is thought to occur due to mechanical damage of thyroid follicles by vigorous palpation. Palpation of the thyroid gland may impair the physical integrity of the follicular basement membrane, with consequent development of an inflammatory response. The majority of patients are asymptomatic, however clinically significant thyrotoxicosis occurs in a minority. Patients should be advised of thyroiditis/thyrotoxicosis as a potential complication of the procedure. Testing of thyroid function should be performed if clinically indicated, particularly if adrenergic symptoms occur post-operatively with no other cause identified.
Publisher: MDPI AG
Date: 27-04-2020
Abstract: Gestational diabetes (GDM) increases the risk of pregnancy complications. However, these risks are not the same for all affected women and may be mediated by inter-related factors including ethnicity, body mass index and gestational weight gain. This study was conducted to identify, compare, and critically appraise prognostic prediction models for pregnancy complications in women with gestational diabetes (GDM). A systematic review of prognostic prediction models for pregnancy complications in women with GDM was conducted. Critical appraisal was conducted using the prediction model risk of bias assessment tool (PROBAST). Five prediction modelling studies were identified, from which ten prognostic models primarily intended to predict pregnancy complications related to GDM were developed. While the composition of the pregnancy complications predicted varied, the delivery of a large-for-gestational age neonate was the subject of prediction in four studies, either alone or as a component of a composite outcome. Glycaemic measures and body mass index were selected as predictors in four studies. Model evaluation was limited to internal validation in four studies and not reported in the fifth. Performance was inadequately reported with no useful measures of calibration nor formal evaluation of clinical usefulness. Critical appraisal using PROBAST revealed that all studies were subject to a high risk of bias overall driven by methodologic limitations in statistical analysis. This review demonstrates the potential for prediction models to provide an in idualised absolute risk of pregnancy complications for women affected by GDM. However, at present, a lack of external validation and high risk of bias limit clinical application. Future model development and validation should utilise the latest methodological advances in prediction modelling to achieve the evolution required to create a useful clinical tool. Such a tool may enhance clinical decision-making and support a risk-stratified approach to the management of GDM. Systematic review registration: PROSPERO CRD42019115223.
Publisher: Wiley
Date: 14-10-2020
Publisher: Springer Science and Business Media LLC
Date: 26-01-2018
Publisher: Cold Spring Harbor Laboratory
Date: 07-12-2021
DOI: 10.1101/2021.12.05.21267329
Abstract: The Monash early pregnancy prediction model calculates risks of developing GDM and is internationally externally validated and implemented in practice, however some gaps remain. To validate and update Monash GDM model, revising ethnicity categorisation, updating to recent diagnostic criteria, to improve performance and generalisability. Routine health data for singleton pregnancies from 2016 to 2018 in Australia included updated GDM diagnostic criteria. The Original Model predictors were included (age, body mass index, ethnicity, diabetes family history, past-history of GDM, past-history of poor obstetric outcomes, ethnicity), with ethnicity revised. Updating model methods were: recalibration-in-the-large (Model A) re-estimation of intercept and slope (Model B), and coefficients revision using logistic regression (Mode1 C1 with original eight ethnicity categories, and Mode1 C2 with updated 6 ethnicity categories). Analysis included ten-fold cross-validation, performance measures (c-statistic, calibration-in-the-large value, calibration slope and expected-observed (E:O) ratio) and closed testing examining log-likelihood scores and AIC compared models. In 26,474 singleton pregnancies (4,756, 18% with GDM), we showed that temporal validation of the original model was reasonable ( c -statistic 0.698) but with suboptimal calibration (E:O of 0.485). Model C2 was preferred, because of the high c-statistic (0.732), and it performed significantly better in closed testing compared to other models. Updating of the original model sustains predictive performance in a contemporary population, including ethnicity data, recent diagnostic criteria, and universal screening context. This supports the value of risk prediction models to guide risk-stratified care to women at risk of GDM. This study was registered as part of the PeRSonal GDM study on the Australian and New Zealand Clinical Trials Registry (ACTRN12620000915954) Pre-results.
Publisher: Springer Science and Business Media LLC
Date: 20-03-2020
DOI: 10.1007/S00125-020-05123-6
Abstract: The aim of this systematic review was to develop core outcome sets (COSs) for trials evaluating interventions for the prevention or treatment of gestational diabetes mellitus (GDM). We identified previously reported outcomes through a systematic review of the literature. These outcomes were presented to key stakeholders (including patient representatives, researchers and clinicians) for prioritisation using a three-round, e-Delphi study. A priori consensus criteria informed which outcomes were brought forward for discussion at a face-to-face consensus meeting where the COS was finalised. Our review identified 74 GDM prevention and 116 GDM treatment outcomes, which were presented to stakeholders in round 1 of the e-Delphi study. Round 1 was completed by 173 stakeholders, 70% (121/173) of whom went on to complete round 2 84% (102/121) of round 2 responders completed round 3. Twenty-two GDM prevention outcomes and 30 GDM treatment outcomes were discussed at the consensus meeting. Owing to significant overlap between included prevention and treatment outcomes, consensus meeting stakeholders agreed to develop a single prevention/treatment COS. Fourteen outcomes were included in the final COS. These consisted of six maternal outcomes (GDM diagnosis, adherence to the intervention, hypertensive disorders of pregnancy, requirement and type of pharmacological therapy for hyperglycaemia, gestational weight gain and mode of birth) and eight neonatal outcomes (birthweight, large for gestational age, small for gestational age, gestational age at birth, preterm birth, neonatal hypoglycaemia, neonatal death and stillbirth). This COS will enable future GDM prevention and treatment trials to measure similar outcomes that matter to stakeholders and facilitate comparison and combination of these studies. This study was registered prospectively with the Core Outcome Measures in Effectiveness Trials (COMET) database: tudies/details/686/
Publisher: Elsevier BV
Date: 02-2021
DOI: 10.1111/AJT.16145
Publisher: Wiley
Date: 19-10-2019
DOI: 10.1111/OBR.12762
Abstract: Women with polycystic ovary syndrome (PCOS) have increased risk of metabolic syndrome. The relative contribution of clinical, demographic or biochemical factors to metabolic syndrome in PCOS is not known. A literature search was conducted in MEDLINE, CINAHL, EMBASE and clinical trial registries. Of 4530 studies reviewed, 59 were included in the systematic review and 27 in the meta-analysis and meta-regression. In good and fair quality studies, women with PCOS had an overall increased prevalence of metabolic syndrome (odds ratio, OR 3.35, 95% confidence interval, CI 2.44, 4.59). Increased prevalence of metabolic syndrome occurred in overweight or obese women with PCOS (OR 1.88, 95% 1.16, 3.04) but not in lean women (OR 1.45, 95% CI 0.35, 6.12). In meta-regression analyses, the markers of metabolic syndrome diagnostic criteria (waist circumference, high-density lipoprotein cholesterol, triglyceride, blood pressure), BMI, glucose tolerance (2-hr oral glucose tolerance test) and surrogate markers of insulin resistance (HOMA-IR) but not markers of reproductive dysfunction (sex hormone binding globulin, testosterone, PCOS phenotypes) contributed significantly to the heterogeneity in the prevalence of metabolic syndrome. Women with PCOS have increased risk of metabolic syndrome which was associated with obesity and metabolic features but not with indices of hyperandrogenism.
Publisher: Georg Thieme Verlag KG
Date: 11-2020
Abstract: Gestational diabetes mellitus (GDM) is common and is associated with an increased risk of adverse pregnancy outcomes. However, the prevailing one-size-fits-all approach that treats all women with GDM as having equivalent risk needs revision, given the clinical heterogeneity of GDM, the limitations of a population-based approach to risk, and the need to move beyond a glucocentric focus to address other intersecting risk factors. To address these challenges, we propose using a clinical prediction model for adverse pregnancy outcomes to guide risk-stratified approaches to treatment tailored to the in idual needs of women with GDM. This will allow preventative and therapeutic interventions to be delivered to those who will maximally benefit, sparing expense, and harm for those at a lower risk.
Publisher: Elsevier BV
Date: 10-2022
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2011
Publisher: Elsevier BV
Date: 07-2010
DOI: 10.1016/J.HLC.2010.02.009
Abstract: Robotic mitral valve repair has been performed in Australia since 2004. The aim of this study was to perform a cost-analysis of robotic mitral valve repair (MVR) with direct comparison to conventional MVR surgery. All isolated MVRs performed within one metropolitan hospital network, between June 2005 and June 2008, were retrospectively compared. Ad hoc cost analysis was conducted. There were 107 robotic and 40 conventional MVRs performed. The post-operative degrees of mitral regurgitation were comparable. Total operating time was 18% longer in robotic compared to conventional (239 min vs. 202 min, p<0.001, 95% CI: 11-27%). In robotic, Intensive Care Unit stay was reduced by 19% (p=0.002, 37 h vs. 45 h), and length of hospital stay was reduced by 26% (p<0.001, 6.47 days vs. 8.76 days). Mean hospital cost, without including capital costs, was not significantly increased (AUD$18,503 vs. AUD$17,880 p=0.176, 95% CI: -282 to 1,530). Robotic mitral repair can be performed with similar immediate repair success rates as conventional surgery with a shorter recovery time, but a slightly longer operative time. There is no significant increase in cost over conventional surgery.
Publisher: Elsevier BV
Date: 02-2009
Publisher: Oxford University Press (OUP)
Date: 26-03-2018
Abstract: Our prior meta-analyses demonstrated an increased prevalence of impaired glucose tolerance (IGT) and type 2 diabetes mellitus (T2DM) with polycystic ovary syndrome (PCOS), but with substantial clinical heterogeneity. We aimed to update our previous review to quantify the prevalence of IGT and T2DM in PCOS with only quality studies (good and fair quality). We also aimed to examine the contribution of parameters including ethnicity, obesity and method of diagnosing T2DM in explaining the observed heterogeneity in IGT and T2DM prevalence in PCOS. We conducted a literature search (MEDLINE, CINAHL, EMBASE, clinical trial registries and hand-searching) up to June 2016 to identify studies reporting the prevalence of dysglycemia (IGT and T2DM) in women with and without PCOS. We included studies where women with PCOS (defined according to original National Institute of Health) were compared to women without PCOS for the end-points of the prevalence of IGT or T2DM. We excluded case reports, case series, editorials, and narrative reviews. Studies where PCOS was diagnosed by self-report, or where IGT or T2DM were measured by fasting glucose, only were excluded. We assessed the methodological quality of the included studies using a priori criteria based on the Newcastle-Ottawa Scaling (NOS) for non-randomized studies. Data are presented as odds ratio (OR) (95% CI) with random-effects meta-analysis by Mantel-Haenszel methods. We assessed the contribution of demographic and clinical factors to heterogeneity using subgroup and meta-regression analysis. We reviewed 4530 studies and included 40 eligible studies in the final analysis. On meta-analysis of quality studies, women with PCOS had an increased prevalence of IGT (OR = 3.26, 95% CI: 2.17-4.90) and T2DM (OR = 2.87, 95% CI: 1.44-5.72), which differed by ethnicity (for IGT, Asia: 5-fold, the Americas: 4-fold and Europe: 3-fold), was higher with obesity, and doubled among studies using self-report or administrative data for diagnosing diabetes. The ethnicity-related difference retained its significance for Asia and Europe in BMI-matched subgroups. Clear contributors to heterogeneity did not emerge in meta-regression. Our findings underscore the importance of PCOS as a cause of dysglycemia with a higher prevalence of IGT and T2DM. They support the relevance of ethnicity and obesity and emphasize the need for accurate diagnostic methods for diabetes. CRD42017056524.
Publisher: Elsevier BV
Date: 10-2019
DOI: 10.1016/J.MATURITAS.2019.07.021
Abstract: Osteoporosis is a key concern of women with premature ovarian insufficiency (POI) but there are gaps in clinicians' knowledge of bone health. 1) To systematically evaluate the quality of clinical practice guidelines (CPGs) related to POI and bone health 2) to formulate a management algorithm. Systematic search for English-language clinical practice guidelines (CPGs) from August 2012 to August 2017 (PROSPERO registration number CRD42017075143). Four reviewers independently evaluated the methodological quality of included CPGs using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument (comprising 23 items across 6 domains) using the My AGREE PLUS platform. Inter-rater reliability was assessed using the intraclass correlation coefficient (ICC). In idual domain and total percentage scores were calculated for each CPG. Data from high-scoring CPGs were extracted and summarised to develop the algorithm, with subsequent refinement via expert and end-user clinician feedback. The systematic search yielded 16 CPGs for appraisal. ICC values were 0.71 (good) to 0.95 (very good). The quality of the CPGs was appraised as "high" in 4 cases, "average" in 8 and "low" in 4. High-quality CPGs had mean total scores of 82-96%. Recommendations from high-quality CPGs were summarised into 6 categories: screening risk factors initial assessment diagnosis subsequent assessment and management. Only "management" had recommendations (moderate-quality to low-quality evidence) from all four high-quality CPGs. Limitations are reflected in the algorithm. Most CPGs regarding bone health and POI are of average to poor quality. High-quality CPGs have evidence limitations and recommendation gaps indicating the need for further research.
Publisher: Wiley
Date: 03-08-2021
Abstract: To develop a core outcome set (COS) for randomised controlled trials (RCTs) evaluating the effectiveness of interventions for the treatment of pregnant women with pregestational diabetes mellitus (PGDM). A consensus developmental study. International. Two hundred and five stakeholders completed the first round. The study consisted of three components. (1) A systematic review of the literature to produce a list of outcomes reported in RCTs assessing the effectiveness of interventions for the treatment of pregnant women with PGDM. (2) A three‐round, online eDelphi survey to prioritise these outcomes by international stakeholders (including healthcare professionals, researchers and women with PGDM). (3) A consensus meeting where stakeholders from each group decided on the final COS. All outcomes were extracted from the literature. We extracted 131 unique outcomes from 67 records meeting the full inclusion criteria. Of the 205 stakeholders who completed the first round, 174/205 (85%) and 165/174 (95%) completed rounds 2 and 3, respectively. Participants at the subsequent consensus meeting chose 19 outcomes for inclusion into the COS: trimester‐specific haemoglobin A1c, maternal weight gain during pregnancy, severe maternal hypoglycaemia, diabetic ketoacidosis, miscarriage, pregnancy‐induced hypertension, pre‐ecl sia, maternal death, birthweight, large for gestational age, small for gestational age, gestational age at birth, preterm birth, mode of birth, shoulder dystocia, neonatal hypoglycaemia, congenital malformations, stillbirth and neonatal death. This COS will enable better comparison between RCTs to produce robust evidence synthesis, improve trial reporting and optimise research efficiency in studies assessing treatment of pregnant women with PGDM. 165 key stakeholders have developed #Treatment #CoreOutcomes in pregnant women with #diabetes existing before pregnancy.
Publisher: Elsevier BV
Date: 10-2010
Publisher: Wiley
Date: 10-2018
DOI: 10.1111/AJO.12829
Publisher: Elsevier BV
Date: 09-2023
Location: United Kingdom of Great Britain and Northern Ireland
Location: Australia
Start Date: 2018
End Date: 2020
Funder: National Health and Medical Research Council
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