Current Australian Guidelines Research Articles

Helicobacter pylori antimicrobial resistance in Melbourne, Australia. Time to review therapeutic guidelines?

Antimicrobial resistance (AMR) in Helicobacter pylori is a global concern. The AMR data to inform the Australian Therapeutic Guidelines are based on data over 20 years old. To evaluate the frequency of AMR in H. pylori isolates from gastric biopsy specimens received in our laboratory in Melbourne, Australia. To review the literature on resistance rates in Australia and compare historic data. A retrospective, observational study summarising AMR rates in all H. pylori isolates from our laboratory from 2015 to June 2020. Microbiology laboratory in metropolitan Melbourne, Australia, receiving referrals from private hospitals, gastroenterology clinics and endoscopy suites. Population minimum inhibitory concentration distributions and frequency of resistance to clarithromycin, amoxicillin, metronidazole and tetracycline in H. pylori isolates. Three hundred and eighty-six H. pylori isolates with susceptibility testing data were identified. The frequency of resistance in this cohort was: clarithromycin 89.9%, amoxicillin 23.5%, metronidazole 66.1% and tetracycline 4.4%. Comparison with historical data may suggest increasing AMR rates in Australia. The main limitation is the lack of treatment history to correlate AMR results. Definitive conclusions from this cohort cannot be made, but trends suggest rising levels of primary H. pylori AMR rates in Australia. This has important implications for empirical treatment decision making and treatment outcomes. Primary H. pylori AMR requires dedicated studies and current Australian therapeutic guideline recommendations may require re-evaluation. We propose considerations for improving the management of H. pylori in Australia. A centralised public health approach to H. pylori AMR surveillance should be established.

New Australian guidelines for the treatment of alcohol problems: an overview of recommendations.

New Australian guidelines for the treatment of alcohol problems: an overview of recommendations.

Why is there variation in test ordering practices for patients presenting to the emergency department with undifferentiated chest pain? A qualitative study

IntroductionUp to one-third of laboratory tests ordered in the ED for adults presenting with undifferentiated chest pain are generally not indicated by current Australian guidelines. This study set out to...

Acute granulomatous interstitial nephritis in a patient with metastatic melanoma on targeted therapy with dabrafenib and trametinib—A case report

BackgroundCombination molecular targeted therapy with dabrafenib plus trametinib has been shown to improve progression‐free survival and overall survival in patients with BRAF V600 mutated unresectable or metastatic melanoma. In general, these agents are well tolerated. Kidney related adverse events are uncommon with only three case reports of acute interstitial nephritis and one case of a serious acute kidney injury. We report another case of interstitial nephritis related to these drugs.CaseA 37‐year‐old man diagnosed with metastatic melanoma (BRAF V600E mutation) who developed acute interstitial nephritis 5 years into his treatment with combination dabrafenib plus trametinib therapy. He presented with an asymptomatic acute kidney injury on routine surveillance pathology with a creatinine of 174 μmol/L (from baseline 80 μmol/L) and a corresponding estimated glomerular filtration rate (eGFR) of 42 ml/min/1.73 m2 (from a baseline >90 ml/min/1.73 m2) and microalbuminuria (albumin creatinine ratio [ACR] 8.5 mg/mmol). Renal biopsy revealed a granulomatous interstitial nephritis likely drug related. He was treated with prednisolone 1 mg/kg and ceased his targeted therapy with improvement in his renal function.ConclusionAlthough rare, recognition of acute interstitial nephritis, a possible serious adverse outcome due to dabrafenib and trametinib is important and needs to be incorporated into current Australian cancer therapy guidelines.

Primary care management of chronic insomnia: a qualitative analysis of the attitudes and experiences of Australian general practitioners

BackgroundChronic insomnia is a highly prevalent disorder, with ten to thirty percent of Australian adults reporting chronic difficulties falling asleep and/or staying asleep such that it causes significant daytime impairment. Current Australian general practice guidelines recommend cognitive behavioural therapy for insomnia (CBTi) as first line treatment for insomnia, however research suggests that most general practice consultations for insomnia result in a prescription for hypnotic or sedative medicines. Although the first point of contact for patients experiencing symptoms of insomnia is often general practice, little is known about the current role, experiences and capacity of Australian general practitioners to manage insomnia. This study aimed to address that gap by exploring the attitudes and opinions of general practitioners regarding insomnia management, to inform the development and implementation of new models of best practice insomnia care within general practice.MethodsA descriptive, pragmatic qualitative study. Purposive sampling was used to recruit practising Australian general practitioners, varying in age, years of experience and geographic location. Semi-structured interviews were conducted, and data analysed using thematic analysis. ResultsTwenty-eight general practitioners participated in the study. Three major themes were identified: 1) Responsibility for insomnia care; 2) Complexities in managing insomnia; and 3) Navigating treatment pathways. Whilst general practitioners readily accepted responsibility for the management of insomnia, provision of care was often demanding and difficult within the funding and time constraints of general practice. Patients presenting with comorbid mental health conditions and insomnia, and decision-making regarding long-term use of benzodiazepines presented challenges for general practitioners. Whilst general practitioners confidently provided sleep hygiene education to patients, their knowledge and experience of CBTi, and access and understanding of specialised referral pathways for insomnia was limited. ConclusionsGeneral practitioners report that whilst assessing and managing insomnia can be demanding, it is an integral part of general practice. Insomnia presents complexities for general practitioners. Greater clarity about funding options, targeted education about effective insomnia treatments, and referral pathways to specialist services, such as benzodiazepine withdrawal support and psychologists, would benefit insomnia management within general practice.

Australia-wide cross-sectional survey of general practitioners' knowledge and practice of lung cancer screening.

Low-dose computed tomography (LDCT) screening can reduce lung cancer deaths in high-risk individuals, yet current Australian guidelines do not recommend screening. Little is known about current screening practices in Australia. To evaluate the proportion of general practitioners who report ordering lung cancer screening for their patients, identify factors associated with ordering lung cancer screening and assess general practitioners (GP) rationale for recommending screening and preference of composition of any future national targeted screening programme. A survey was distributed to a nationally representative sample of 4000 Australian GP. The questionnaire included respondent demographics, self-reported screening practices, knowledge of screening recommendations, recent screening education, preference for recruitment methodologies for potential screening programmes and potential factors influencing the screening practices of GP. Two logistic regression models identified factors associated with self-reported chest X-ray (CXR) and LDCT screening within the past 12 months. A total of 323 GP completed the survey (participation rate 8.1%). Participants were mostly females (50.6%), from collective/group (79.1%) and metropolitan-based practices (73.5%). Despite the majority of responders understanding that screening is not recommended by Australian professional societies (71.2%), a substantial proportion of participants requested a CXR or LDCT screening (46.4% and 20.8% respectively). A variety of shared (GP reassurance, affordability of screening, believing screening is funded) and unique practice, educational and cognitive factors were associated with self-reported LDCT and CXR screening, with the strongest association being recent education about screening from radiology practices (odds ratio (aOR) for LDCT screening 10.4, P < 0.001). In Australia, lung cancer screening occurs outside a coordinated programme, and there is discordance between practice and national recommendations. This highlights an urgent need for clearer guidance from national and professional bodies.

Comparative embryo/larval sensitivity of Australian marine bivalves to ten metals: A disjunct between physiology and phylogeny

Metal contamination within the urbanized coastal zon is one threat linked to a decline in the abundance, distribution and/or species diversity of wild marine bivalve populations. This study determined the 48-h embryo/larval sensitivity (no-effect concentration (NEC) and median-effect concentration (EC50)) of ten marine bivalve species (nine endemic to Australia) to aluminium (Al), cadmium (Cd), chromium (Cr), cobalt (Co), copper (Cu), iron (Fe), lead (Pb), manganese (Mn), nickel (Ni) and zinc (Zn), key metal contaminants impacting urbanized coastal zones in south-eastern Australia, in natural seawater (20–22 °C, 30‰ salinity, pH 7.8–7.9, 1.2 mg/L dissolved organic carbon). For all metals, except Fe, the order of sensitivity was oysters > mussels ≥ scallops ≥ cockles ≥ clams, where the economically-important oysters, Magallana gigas and Saccostrea glomerata, were 2.6 (Al) to 4.2 (Cd) times more sensitive than the least sensitive clam species. For all bivalve species, the order of metal sensitivity was Cu > Pb > Zn = Ni > Co > Cd > Al > Cr(VI) > Mn ≥ Fe(III), where Cu was eight times more toxic than Zn or Ni, 28 times more toxic than Cd, 220 times more toxic than Cr(VI) and 570 times more toxic than Fe(III). Iron, unlike the other nine soluble metals, occurred as particulate Fe(III) oxyhydroxide, where EC50 values decreased with increasing exposure time as the larval (D-veliger) stage. There was no significant (p > 0.05) effect of embryo/larval mass, or surface area/volume, on metal sensitivity. Further, there was no significant (p > 0.05) relationship between metal sensitivity and phylogeny (genetic distance). Divalent metal sensitivity was positively related (r2 = 0.87) to cell surface metal-binding affinity. The current Australian marine water quality guideline for Ni is not protective of the ten bivalve species (NECs were 2–6-fold below the guideline), while the guideline for Zn is not protective of oysters.

Characterising leaf petiole, blade and bunchstem nutrient concentration across three grapevine cultivars

Background and Aims Tissue nutrient concentration is useful for determining vine nutritional status and managing vineyard nutrition. Current Australian guidelines are based on the analysis of petioles at flowering and leaf blades at veraison, sampled adjacent to the basal inflorescence and bunch. The comparative value of these two tissue types and that of the bunchstem for assessing plant nutrient status at the two phenological stages is required. Moreover, the impact of node position and cultivar is unclear. Methods and Results We characterised the macro and micronutrients at flowering and veraison of three segments of the petiole, the entire leaf blade and the bunchstem at two node positions of cvs Cabernet Sauvignon, Shiraz and Chardonnay grown under identical conditions. Nutrient concentration was non-uniform along the length of the petiole. The middle segment had the lowest concentration of most macronutrients, while Mn was generally highest in the middle segment. When averaged across petioles, blades and bunchstems the lower node had a higher nutrient concentration than the upper node, except for K. The concentration of some nutrients within the leaf blade was correlated with those of the petiole but this was dependent on the cultivar and the time of sampling. The nutrient concentration of the bunchstem was more closely correlated to the petiole than to the blade. Cultivar differences were also apparent, but this depended on the individual nutrient and the sampling time. Conclusions Nutrient concentration was inconsistent along the length of the petiole. The nutrient concentration of petioles, blades and bunchstems was node, cultivar and time specific. Therefore, tissue nutrient analysis will be meaningful only if sampling is consistent across these variables. Significance of the Study These results will aid in the formation of better sampling protocols for accurate grapevine nutrient diagnosis.

METHODS TO RECTIFY DISCREPANCIES WITH ADULT BLOOD PRESSURE GUIDELINES

Objective: The American Academy of Pediatrics (AAP) guidelines for screening and managing high blood pressure (BP) for children and adolescents are commonly used for Australian children. These were updated in 2017 to remain consistent with recommendations for adults in the United States (hypertension defined as &gt;=130/80mmHg), which differ from guidelines for Australian adults (&gt;=140/90mmHg). We sought to investigate the applicability of the AAP guidelines to define BP thresholds for Australian children. Design and method: The West Australian Pregnancy Cohort (Raine) Study has followed since birth a cohort of 2868 children born between 1989–1991. BP was measured at 3/5/8/10/14/17 years, in the seated position after 5 minutes rest, using an oscillometric sphygmomanometer (Dinamap™). Three readings were taken every 2 minutes until the 10-year visit, and subsequently 6 readings every 2 minutes, with the first measurement discarded and mean of following results calculated to give the BP value. Centile curves were constructed by the LMS method, adjusted for height and stratified by sex, and then compared to the published AAP centile curves. In this analysis we focus on systolic BP (SBP). Results: 2202 participants were included, contributing 7850 observations (1127 males, 51.2%). The 95th SBP centile according to the fitted curves for a child on the 50th height centile are displayed in Fig. 1, along with equivalent AAP curves. The fitted were higher than the AAP curves for both sexes in early and mid-childhood, before converging in adolescence for females but not males in whom the fitted curve approached 140mmHg at 18 years. Comparing absolute BP thresholds, 13.5% of children had an SBP &gt;=130mmHg between 14 and 18 years of age, but only 3.0% had an SBP &gt;=140mmHg. Conclusions: Using data from Australian children and adolescents to define the threshold for hypertension led to curves more congruous with current Australian adult hypertension guidelines. Sex stratification better represents physiologic changes in BP, but again leads to inconsistencies between paediatric and adult guidelines. A better method would be to develop net-benefit or risk-based guidelines based on future clinical events or phenotypes, which we aim to do in future work.

Diets within Environmental Limits: The Climate Impact of Current and Recommended Australian Diets.

Planetary boundaries are an important sustainability concept, defining absolute limits for resource use and emissions that need to be respected to avoid major and potentially irreversible earth system change. To remain within the safe operating space for humanity, there is a need for urgent adoption of climate-neutral diets, which make no additional contribution to warming. In the first study of its kind, a new climate metric, the Global Warming Potential Star (GWP*), was used to assess greenhouse gas (GHG) emissions associated with 9341 Australian adult diets obtained from the Australian Health Survey. Dietary climate footprints averaged 3.4 kg CO2-equivelent per person per day, with total energy intake explaining around one quarter of the variation. Energy-dense and nutrient-poor discretionary foods contributed around one third. With lower climate footprint food choices, a diet consistent with current Australian dietary guidelines had a 42% lower climate footprint. Currently, it is not possible to define a climate-neutral dietary strategy in Australia because there are very few climate-neutral foods in the Australian food system. To bring Australian diets into line with the climate stabilization goals of the Paris Agreement, the most important need is for innovation across the agricultural and food processing industries to expand the range of climate-neutral foods available.

Short-Term Guideline Values for Chlorine in Freshwaters.

The current Australian and New Zealand default guideline value of 3 µg Cl/L for total residual chlorine in freshwaters is largely based on acute data converted to chronic data using a default acute to chronic ratio of 10, without consideration of chlorine decomposition. Given the rapid decomposition of chlorine, initially as hypochlorite and then as chloramine, it is appropriate to consider a guideline value based on short-term (acute) toxicity rather than one based on longer-term chronic data, as has been recommended for chlorine in marine waters. The literature on the fate of chlorine in drinking water discharged to freshwaters and on the ecotoxicity of total residual chlorine has been reviewed, and on the basis of this, revised default guideline values were derived for both hypochlorite and chloramine in freshwater using a species sensitivity distribution of toxicity data. The values for 95% species protection were 7 and 9 µg Cl/L as total residual chlorine, respectively. The former would apply to any total residual chlorine-containing effluent, but in the case of drinking water where dechlorination has been undertaken, the chloramine-based default guideline value is likely to be more appropriate. Both are likely to be conservative because they were largely based on toxicity testing under continuous flow-through conditions. They will apply at the edge of the mixing zone, and the variable receiving water concentration at this point might best be determined from a time-weighted average total residual chlorine concentration. Environ Toxicol Chem 2021;40:1341-1352. © 2021 SETAC.

Adequacy of cool running water first aid by healthcare professionals in the treatment of paediatric burns: Across-sectional study of 4537 children.

ObjectiveTo determine the adequacy of cool running water first aid provided by healthcare professionals in the early management of children with thermal burn injuries.MethodsA cross‐sectional study was undertaken using a prospectively collected registry of children who presented with a thermal burn to the only major paediatric burns centre in Queensland, Australia, from January 2013 to December 2018. Main outcome measures included the type and duration of first aid administered by paramedics, general practitioners and emergency providers at local general hospitals and a children's hospital. In accordance with current Australian guidelines, adequate cooling was defined as 20 min of cool running water within 3 h of the injury.ResultsOf the 4537 children who presented to the paediatric burns centre, 3261 (71.9%) received adequate first aid, including 1502 (33.1%) at the scene of injury. Paramedics and general practitioners administered adequate cooling to 184 (25.0%) and 52 (24.2%) of their patients, respectively. ED clinicians adhered to guidelines in the treatment of 1019 (56.3%) children at general hospitals and 411 (76.0%) at the children's hospital. Among ED patients who presented with incomplete prior first aid, the risk of inadequate cooling was significantly greater for those transported via ambulance (P < 0.001).ConclusionDeficiencies remain in the cooling of paediatric burns patients at all levels of initial management. There is a need in the healthcare community for improved education regarding the parameters and clinical benefits of cool running water first aid.

Trimethoprim‐sulfamethoxazole as Pneumocystis jiroveci pneumonia prevention in patients undergoing methotrexate therapy for hematological malignancies: A review of the literature

AbstractMethotrexate is a cytotoxic agent that is commonly used to treat autoimmune diseases, and both solid and hematological malignancies. Drug interactions are of particular concern during methotrexate therapy, as they have the potential to alter the pharmacokinetics of methotrexate and lead to significant toxicity. One agent that has the potential to interact with methotrexate is the antimicrobial agent trimethoprim with sulfamethoxazole. Consideration of this interaction is of importance in patients that are undergoing high‐dose methotrexate therapy for hematological malignancies as trimethoprim/sulfamethoxazole is the preferred agent for Pneumocystis jiroveci pneumonia prophylaxis. Current Australian guidelines recommend avoiding concurrent administration of high‐dose methotrexate and trimethoprim/sulfamethoxazole, yet evidence to support this recommendation is unclear. This review investigates the current available evidence that focuses on the interaction between high‐dose methotrexate and trimethoprim/sulfamethoxazole and aims provide guidance for the use of this combination in clinical practice.

Environmental Methamphetamine Exposures and Health Effects in 25 Case Studies.

The clandestine manufacture and use of methamphetamine can result in contamination of residential properties. It is understood that this contamination remains in homes for a significant period, however there are a lack of data available to understand the health effects of exposure to environmental methamphetamine contamination (third-hand exposure). Our study collected information from 63 individuals in 25 separate case studies where the subjects had unwittingly suffered third-hand exposure to methamphetamine from former manufacture, use, or both. Data included environmental contamination data, information on subjects’ health effects, and evidence of exposure using hair analysis. This study identified a range of health effects that occur from residing in these properties, including behavioural effects or issues, sleep issues, respiratory effects, skin and eye effects, and headaches. Methamphetamine was detected in hair samples from some individuals, including children. The exposures and concomitant reported health effects covered a wide range of environmental methamphetamine levels in the properties, including low levels close to the current Australian guideline of 0.5 µg methamphetamine/100 cm2. There were no discernible differences between health effects from living in properties contaminated from former manufacture or use. This study demonstrates that residing in these properties can represent a serious public health risk.

Australia's national zoster vaccination program: Knowledge, attitudes and behaviour of general practitioners.

To assess knowledge, attitudes and behaviour of Australian general practitioners (GPs) regarding herpes zoster vaccination under the National Immunisation Program (NIP) from 2016 for adults aged 70-79 years. National cross-sectional online survey of GPs, October-November 2017. Knowledge, attitudes and behaviour regarding zoster vaccination, including challenges experienced and recommendations for improvement. Of the 1026 GPs who responded (response rate 7.9%), 98.5% were aware that zoster vaccine is NIP-funded for adults aged 70-79 years and 85.4% that it is recommended for age 60-69 years; however, 51.3% incorrectly thought it is routinely recommended for age 50-59 years. A minority (4.6%) incorrectly believed that being immunocompromised is not a contraindication to zoster vaccination and 16.0% that it cannot be co-administered with influenza or pneumococcal vaccine. Almost half (48.9%) rarely or never reported zoster vaccination data to the Australian Immunisation Register (AIR). Challenges perceived included lack of adequate information on vaccine contraindications; efficacy and safety concerns; and difficulty applying age criteria for NIP eligibility in general practice. Respondents indicated a desire for program expansion to include younger and older adult age groups. This Australian GP survey, conducted one year after the introduction of the national zoster vaccination program, identified some knowledge gaps. A repeat survey of GPs is warranted to determine whether these issues persist, particularly regarding contraindication to vaccination for immunocompromised individuals. We encourage all GPs to offer zoster vaccination in line with current Australian evidence-based guidelines, particularly for the NIP-funded 70-79 years cohort; ensuring compliance with relevant contraindications; and reporting to AIR.

Polyps of the Jellyfish Aurelia aurita Are Unaffected by Chronic Exposure to a Combination of Pesticides.

Pesticides are a major contaminant in coastal waters and can cause adverse effects in marine invertebrates such as jellyfish. Most studies have investigated short-term responses of organisms to unrealistically high concentrations of pesticides; however, chronic exposure to persistent low concentrations, which are more likely to occur in the environment, are rarely analyzed. We tested the response of polyps of the moon jellyfish Aurelia aurita to environmental concentrations of the herbicide atrazine and the insecticide chlorpyrifos, individually and in combination, over 9 wk. We hypothesized that exposure to individual pesticides would reduce rates of asexual reproduction and alter polyps' metabolite profiles, and that the results would be more severe when polyps were exposed to the combined pesticides. Polyps survived and reproduced (through budding) in all treatments, and no differences among treatments were observed. Proton nuclear magnetic resonance spectroscopy revealed no difference in profiles of polar metabolites of polyps exposed to the individual or combined pesticides. Our results suggest that A. aurita polyps are unaffected by chronic exposure to atrazine and chlorpyrifos at concentrations recommended as being protective by current Australian water quality guidelines. Environ Toxicol Chem 2020;39:1685-1692. © 2020 SETAC.

Pharmacokinetic modeling to determine the minimum effective dose of disease-specific antibodies for preventing hepatitis A post-exposure

ABSTRACT Background The minimum effective dose of intramuscular polyvalent immune globulin for prevention of hepatitis A post-exposure is unknown. In Australia current dosing is according to weight category. Methods The peak concentration and decay of hepatitis A antibodies after intramuscular dosing of immune globulin in adults was modeled utilizing published parameters. Models simulated dosing according to current Australian guidelines, then adjusted the dose in clinically relevant increments to estimate the optimal dose of hepatitis A antibodies for post-exposure prophylaxis of nonimmune individuals. Optimal dosing assumed a target serum concentration of hepatitis A antibodies of the correlate of protection plus a 10% margin of error at an incubation period. The effect of weight on hepatitis A antibody concentration at an incubation period under current guidelines was examined by fixing weight in 5 kg increments. Results Current dosing guidelines in Australia may underdose people who weigh in excess of 85 kg. The optimal dose of hepatitis A-specific antibodies according to the model was 3.6, 2.5, and 1.9 IU/kg assuming 50%, 75% and 100% bioavailability respectively. Conclusions For individuals in Australia recommended passive immunization as post-exposure prophylaxis and weighing in excess of 85 kg, conservative management would include dosing between 2.5 and 3.6 IU hepatitis A antibodies/kg.

Schistosoma serology after praziquantel treatment of Schistosoma infection in refugee children resettled in Australia: A retrospective analysis

BackgroundThis study aimed to document changes in serological response before and after treatment of Schistosoma infection in resettled refugee children from endemic countries in Australia. Current Australian guidelines recommend serological screening for Schistosoma infection in children and adults from endemic countries. Data on the utility of follow-up serology after treatment is limited. MethodsWe undertook a retrospective audit of Schistosoma serology in refugee-background children presenting to a specialist paediatric refugee health clinic in Melbourne, Australia, between January 2005 and December 2014. Patients were included with positive Schistosoma serology, documented treatment with praziquantel; clinical and serological followup data after treatment, and no return to endemic areas. ResultsFifty-one refugee-background children were included. Overall, 40/51 (78.4%) children had serology that decreased after treatment, 25/51 (49.0%) had a greater than twofold decrease and 22/51 (43.1%) reverted to negative serology. Six (11.8%) children showed an increasing serology titre and 5/51 (9.8%) had unchanged serology after treatment. ConclusionsThis is the first study describing the changes in Schistosoma serological titres following treatment in immigrant children in a non-endemic country. We observed a majority downward trend in antibody titres after praziquantel treatment, suggesting follow-up serological testing may be useful in children to monitor treatment response.

Ensuring donor safety: is venesecting therapeutic donors to haemoglobin levels below Blood Service guidelines safe?

Therapeutic phlebotomy is the cornerstone of treatment for HFE haemochromatosis (HH). Current Australian Red Cross LifeBlood Service guidelines mandate measuring haemoglobin (Hb) levels prior to phlebotomy and if below 130g/l in men or 120g/l in women, donors are deferred from donating whole blood. Therapeutic donation below these levels may take place where both the treating doctor and a blood service medical officer approve. The aim of the current study was to determine whether adverse events are more frequent in those who undergo therapeutic phlebotomy below current Hb thresholds applied to volunteer therapeutic donors. A retrospective review of all therapeutic donations was undertaken for the financial year 2016-2017. The data were obtained through the Australian Red Cross Blood Service. Inclusion criteria were any donor between 16 and 70years of age, weighing more than 50kg and meeting blood service guidelines for donation. All adverse events recorded in an electronic quality system were obtained and associated with donor haemoglobin level. Statistical analyses were performed using analysis of variance or Fisher's exact test (GraphPad Prism). About 34886 therapeutic phlebotomy donations occurred during 2016-2017, of whom the majority were referred for HH (34089). In total, 365 of 34886 donations (0·0105%) were complicated by an adverse event. A total of 305 (0·0087%) therapeutic donations occurred while below the lower limit of blood service Hb threshold for their respective genders. Of the donations that occurred below the blood service threshold, 3 of 305 (0·0098%) had an adverse event compared with 362 of 34581 donations above the lower limit threshold (0·0105%, P=0·99). The incidence of adverse events was not increased in the group which underwent therapeutic phlebotomy below the current Australian Red Cross Blood Service Hb threshold compared with those above threshold, indicating safety of treatment at Hb levels lower than currently recommended.

314 Cost-Effectiveness of Systematic Coronary Artery Calcium Scans Compared with Risk Scoring under Current Australian and US Guidelines

314 Cost-Effectiveness of Systematic Coronary Artery Calcium Scans Compared with Risk Scoring under Current Australian and US Guidelines