Volume 207 Issue 8

Closing the gap in cardiovascular health

Rosemary Wyber · Judith M Katzenellenbogen · Glenn Pearson · Michael Gannon

Following chorioamnionitis, a male infant from a remote Indigenous community was born by vaginal breech delivery at 26 weeks’ gestation

Lachlan J Warren · Dev Tilakaratne · Rakesh Seth

Severe cutaneous adverse drug reactions are a major cause of morbidity and mortality in Australia and recognition is important

Paul Chee

A 30-year-old woman presented with progressive, symmetrical, jagged and reticulate erythema and hyperpigmentation of the lower legs consistent with livedo racemosa

Deshan F Sebaratnam · Nita Agar

A 34-year-old woman presented with a photosensitive rash

Deshan F Sebaratnam · Patricia Lowe

A 36-year-old pregnant woman presented to the emergency department with a 3-day history of uncomfortable, blistering eruption involving both hands

Victoria A Snaidr · Patricia M Lowe

Communication in surgical practice

Christopher J Young

To improve melanoma outcomes, the focus on prevention, early detection and new treatment strategies must continue

B Mark Smithers · Jeff Dunn · H Peter Soyer

Rare and common genetic variants may interact with environmental factors to cause young-onset diabetes

Elaine Chow · Juliana CN Chan

Public health campaigns should emphasise the detection of suspicious de novo lesions, as well as of changing lesions

Yan Pan* · Nikki R Adler* · Rory Wolfe · Catriona A McLean · John W Kelly

The burden of skin cancer is particularly high among patients with multiple lesions (about half of all patients)

Nirmala Pandeya · Catherine M Olsen · David C Whiteman

Diagnosing MODY and neonatal diabetes is important because their management (including family screening) and prognosis can differ significantly from those of types 1 and 2 diabetes

Timothy ME Davis · Ashley E Makepeace · Sian Ellard · Kevin Colclough · Kirsten Peters · Andrew Hattersley · Wendy A Davis

New guidelines provide greater emphasis on atypical presentations of melanoma

Victoria J Mar · Alex J Chamberlain · John W Kelly · William K Murray · John F Thompson

New targeted immunotherapies have had promising results in phase 2 and 3 trials for patients with moderate to severe AD

Victoria R Harris · Alan J Cooper

CAC scoring is a robust and reproducible way of detecting coronary atherosclerosis and estimating future risk of cardiac events

Christian R Hamilton-Craig · Clara K Chow · John F Younger · V M Jelinek · Jonathan Chan · Gary YH Liew

To the Editor:While highlighting the benefits of endovascular clot retrieval (ECR), Hwang and Gawarikar1 identified Victoria as establishing the first statewide 24/7 ECR service in Australia. We agree with the authors’ caution against focusing on a singular therapy for a few patients at the cost of delivering basic, high quality stroke care to all. As they note in the article, offering ECR requires capacity to appropriately assess patients with advanced imaging and to treat or transfer patients if ECR is indicated.1 We want to provide some background to the ECR service and the role of telemedicine for delivering evidence-based stroke care across regional Victoria, including ECR access. In Victoria, stroke telemedicine has been an important linchpin for overcoming clinical practice variation. The Victorian Stroke Telemedicine (VST) program (www.vst.org.au), operational since 2011, is a statewide service providing 16 regional hospitals with remote access to stroke specialists 24/7.2 The first VST patient eligible for ECR was identified in May 2015, with 78 identified to date. The Victorian Government statewide ECR protocol3 was released in May 2016, with VST being pivotal in identifying and transferring suitable patients from regional areas. Working with regional colleagues through telemedicine has led to numerous benefits,4 including capacity building and incorporating the latest evidence into local stroke protocols. So far, 1600 patients have received a VST consultation, the thrombolysis rate for ischaemic stroke under 4.5 hours is 38% (nationally, 24%),5 some hospitals have provided thrombolysis therapy for the first time, more patients are receiving thrombolysis in under 60 minutes and haemorrhagic complications rates are comparable with those of metropolitan hospitals. Moreover, VST delivers a broader neurological service: 38% of VST consultations receive a “not stroke” diagnosis. We agree that attention to guideline adherence (ie, stroke unit access, care plans and preventive medication) is required.1 Telemedicine may improve access to both basic and specialised care, and in our experience, it provides important infrastructure to incorporate new evidence rapidly. If systems of care could be improved to support rapid uptake of evidence, then geographical boundaries may be overcome: a national acute stroke telemedicine service may be one solution. Commensurate with the need to ensure value, we are undertaking a comprehensive cost effectiveness analysis to support optimal stroke care policy and practice decisions.

Kathleen L Bagot · Dominique A Cadilhac · Chris Bladin

In reply

Yun Tae Hwang · Yash Gawarikar

To the Editor:High technology solutions to the difficult task of selecting and monitoring moles (pigmented skin naevi) may be useful to keep accurate records of people’s skin. Adopting military surveillance and warfare technology,1 there are computer algorithms that search for changes in moles’ appearance over time. Deep convolutional neural networks analysis can group them into benign or malignant lesions with high accuracy.2 In a study by Esteva and colleagues,2 the convolutional neural networks algorithm differentiated between benign, malignant or non-neoplastic lesions with about 72% accuracy compared with about 66% accuracy by two dermatologists; for melanocytic lesions, the algorithm had a better sensitivity and specificity performance compared with the average of 21 dermatologists, although these findings still need to be replicated in independent datasets. Despite recent advances, there are still questions about how Australians can benefit from this technology and how it is best integrated into clinical practice. Cancer agencies worldwide do not recommend screening for melanoma, but instead ask people to make skin self-examinations a habit and present to a doctor with moles of concern — although informal screening is widespread in Australia. Apps that provide easy access to personalised risk estimation may alert people to engage in such exams more frequently. Moreover, apps that guide people through the skin self-examination process may also be useful, as most people find this task complex.3 Once people notice a spot or mole, they may seek a clinical skin examination. Evidence that clinical skin exams are beneficial comes from the Queensland melanoma case control study4 and other similar studies that show that they lead to the detection of thinner melanomas. There are many apps that allow people to take and send photos of moles, but these are highly variable in sophistication and costs. Whether such technology is best placed in front of (for filtering out clearly benign lesions) or after a clinician’s diagnosis (for additional validation) is also matter of debate. Apps should not distract from the patient–doctor relationship, as the final decision about excision requires face-to-face consultations. While technology solutions are promising, validation studies have mostly been small, have lacked a control group or have not been replicated in clinical practice. Independent big research initiatives, such as the International Skin Imaging Collaboration Challenge on Skin Lesion Analysis towards Melanoma Detection,5 are underway to take the momentum further. This healthy competition may be just what is needed to take the last steps to eradicate melanoma.

Monika Janda · H Peter Soyer

To the Editor:I congratulate Isbister and colleagues1 for performing a first aid randomised controlled trial on box jellyfish stings (a rarity in toxinology). The result is at variance with other studies on this topic (although they mainly involved North American jellyfish stings).2 I agree with the authors and the accompanying editorial3 that the major weakness in the study was the up to 4-hour delay for treatment with hot water. Unlike the earlier bluebottle stings first aid study performed on the beach,4 this study is performed in the emergency department of the Royal Darwin Hospital, when the pain severity was lessening. Pain severity was the primary study outcome: 25% of the study group had pain scores of less than 26 (hot water) or 20 (ice), which is minimal pain. Only 10% of the study group received opioid analgesia, compared with the results obtained by Currie and Jacups5 in a 14-year prospective observational study of box jellyfish stings in Darwin, where 48% of patients received analgesia, including 30% of patients receiving narcotic analgesia. The article by Currie and Jacups5 also reported that 71% of patients received ice. The current trial1 does not detail if ice (or heat) was applied to patients before enrolling in the study. Moreover, Currie and Jacups5 also reported that 84% of stings occurred in less than 1 m of water and most of the stings occurred on the legs. I am not sure how the temperature of the water in the bucket used for distal limb stings was controlled to maintain a temperature of 45°C. If not well regulated, then this would lessen the benefits of the heat. In addition, I am surprised that the authors have not attempted to use their findings to push for a standardised approach to jellyfish stings in Australia. The Australian Resuscitation Council currently has different first aid advice for stings in the tropics compared with southern Australia.3,6 These results would suggest that heat is equally effective as ice for box jellyfish stings. The authors were concerned about the difficulty in providing hot water as first aid, which is the same problem for southern Australia, where hot water is recommended. Surely, it is time to standardise first aid for jellyfish stings in Australia.

Mark Little

In reply

Geoffrey K Isbister · Bart J Currie

Rob Thomas, president of the Australian Medical Students’ Association, talks about the burning need for universities to teach medical students how to survive in the “real” world of medicine

Cate Swannell

The Doherty Institute acknowledged the contributions of long-time employee Jenny Taplin who died in late 2016. She spent 38 years as a bacteriologist in the Microbiological Diagnostic Unit Public Health Laboratory (MDU PHL) at the University of Melbourne. For much of her time at MDU PHL she headed the Salmonella Reference Section, which also functioned as the regional reference laboratory for the phage-typing of Salmonella Typhi. In 1977 Jenny, along with Sue Dixon from IMVS in South Australia, identified infant milk formula as the cause of a national outbreak of infant gastroenteritis with Salmonella Bredeney. This outbreak greatly influenced future approaches to food-borne disease investigations and food safety requirements. The S Bredeney outbreak helped highlight the need for nationwide Salmonella surveillance. Collaboration between MDU PHL, IMVS, the Commonwealth Department of Health and the Australian Society for Microbiology (ASM) led to the establishment of the National Salmonella Surveillance Scheme (NSSS; now NEPSS, the National Enteric Pathogens Surveillance Scheme). NSSS/NEPSS have been major tools in the epidemiological investigations of salmonellosis and provision of early warning to health authorities of food-borne disease from Salmonellae. http://thedohertyinstitute.createsend1.com/t/ViewEmail/i/F4A97D555AE769252540EF23F30FEDED#Vale University of Melbourne Professor Cordelia Fine has won the prestigious 30th anniversary Royal Society Insight Investment Science Books Prize for her book Testosterone rex: unmaking the myths of our gendered minds. The award is described as the “Booker Prize of science writing” and judges praised Testosterone rex for its “eye-opening, forensic look at gender stereotypes and its urgent call for change”. Professor Fine said she was “deeply honoured to have been awarded the Royal Society Insight Investment Science Book Prize”. Testosterone rex brings together evolutionary science, psychology, neuroscience and social history to move beyond old “nature versus nurture” debates, and disprove the myth that testosterone, or the lack of it, shapes men and women into virtually separate species. It is Professor Fine’s third book, following the critically acclaimed Delusions of gender and A mind of its own. Chosen from a shortlist of six, Professor Fine was awarded a cheque for £25 000 at the ceremony in London on Tuesday 19 September. http://newsroom.melbourne.edu/news/professor-cordelia-fine-wins-prestigious-royal-society-prize Dr Elizabeth Magassy has been appointed as a Deputy Chancellor of the University of Wollongong for a 2-year term effective immediately until 18 August, 2019. Dr Magassy has been in full-time general practice in Wollongong since 1978 and for 10 years worked in general practice obstetrics, delivering around a thousand babies. She is a past president of the Illawarra Medical Association (1995-2000), a past chairman of the Illawarra Division of General Practice (2001-2004), has been chairman of The Figtree Private Hospital Medical Advisory Committee, a member of the NSW General Practice Council, and served as a member of Professional Services Review. She is currently chairman of Radio Doctor Illawarra and in 2005 was appointed as Clinical Associate Professor in Graduate Medicine at UOW. http://media.uow.edu.au/releases/UOW237035.html A Western Sydney University medical student has worked to develop the prototype for an educational app, which has been announced as the overall winner of Elsevier Hacks 2017. Elsevier Hacks is an app-building conference which brings medical students from around the world together with coders and designers. Alice Leung, a WSU MBBS student, travelled to Finland to participate. One of only 16 students selected from more than 1500 applicants – Alice initially pitched the idea to develop a smartphone app that allowed medical students to learn their course material anytime, anywhere. After arriving in Finland, Alice was paired with two developers and two other medical students from the Netherlands and Spain. The team pooled their ideas and skills to develop a functional prototype for a new app, “PatientX”. The app is effectively a “chat bot” – like Siri – which processes and responds to verbal or written instructions. As the winner of Elsevier Hacks 2017, Alice’s team is aiming to continue working on PatientX, and take it to the stage of development and commercialisation. https://www.westernsydney.edu.au/newscentre/news_centre/more_news_stories/elsevier_hacks_win_for_medical_students_innovative_app The University of Western Australia’s Dr Gabrielle Brand was awarded the Flinders University ANZAHPE Award for Excellence in Health Professions Education for her research and innovative resource to support excellence in the delivery of patient-centred health care. The award was presented to Dr Brand at the Australian and New Zealand Association for Health Professional Educators (ANZAHPE) Conference in Adelaide. A narrative researcher within the UWA School of Allied Health, Dr Brand won the award for her design and development of Depth of Field: Exploring Ageing, an innovative, inter-professional, reflective learning resource for current and future health professionals. The resource, which is currently being used as core curricula across the Australian and New Zealand higher education and health care sector, uses documentary style photographs and narrated film of older West Australians to stimulate in-depth discussion, examine unexplored stereotypes and challenge health professional students to widen their views around ageing and promote patient-centred care in preparation for their clinical placements. http://www.news.uwa.edu.au/201708289884/dr-brand-recognised-excellence-health-professional-education